Citation Nr: 1338110 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 08-38 651 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and an anxiety disorder. 2. Entitlement to an effective date earlier than November 3, 2011, for a 100 percent rating for a psychiatric disorder, to include PTSD and an anxiety disorder. REPRESENTATION Appellant represented by: Jeany Mark, Attorney ATTORNEY FOR THE BOARD W.T. Snyder, Counel INTRODUCTION The Veteran had active service from November 1967 to November 1974. 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 Milwaukee, Wisconsin. A January 2007 rating decision granted service connection for an anxiety disorder and assigned an initial 30-percent evaluation, effective June 29, 2006, the day on which VA received the Veteran's claim. Following that decision, in February 2007, the Veteran filed a claim of entitlement to service connection for PTSD due to military sexual trauma. After an appeal, in an October 2008 rating decision, the RO granted the Veteran's claim and assigned a combined 30-percent evaluation for his psychiatric disorder, which included his service-connected PTSD and anxiety disorders, effective back to the date of the original claim-June 2006. In a decision dated in January 2011, the Board allowed a 50-percent rating for the period prior to September 15, 2008, and a 70-percent rating forward from that date. The Veteran appealed the January 2011 Board decision to the United States Court of Appeals For Veterans Claims (Court). In a February 2013 Memorandum decision, the Court set aside the January 2011 Board decision, and remanded the case to the Board for further appellate review consistent with the Motion. See Diorio v. Nicholson, 20 Vet. App. 193 n. 1 (2006) (the Court uses the terms, "set aside" and "vacated" interchangeably). Prior to issuance of the Court's decision, the Veteran perfected an appeal of the February 2011 rating decision that implemented the January 2011 Board decision. That appeal is subsumed by the Court's decision and remand which is now before the Board. In a July 2012 rating decision, the RO awarded a 100 percent rating for the service-connected psychiatric disability, effective November 3, 2011. FINDINGS OF FACT 1. For the periods from June 29, 2006, to December 1, 2007, and from February 11, 2008, to September 15, 2008, the preponderance of the evidence of record shows the Veteran's acquired mental disorders, to include PTSD and anxiety disorder, manifested with occupational and social impairment with reduced reliability and productivity. 2. For the period from December 1, 2007, to February 11, 2008, total impairment attributable to the service-connected psychiatric disability has been shown. 3. For the period September 15, 2008, to November 2, 2011, the preponderance of the evidence of record shows the Veteran's acquired mental disorder, to include PTSD and anxiety disorder, otherwise manifested with deficiencies in most areas, but total impairment was not demonstrated. 4. Excluding the period from December 1, 2007, to February 11, 2008, November 3, 2011, is the earliest date upon which total impairment from the Veteran's acquired mental disorder, was demonstrated. CONCLUSIONS OF LAW 1. For the period from June 29, 2006 to December 1, 2007, and from February 11, 2008, to September 15, 2008, the criteria for an initial evaluation of 50 percent, but no higher, for a psychiatric disorder, to include PTSD and an anxiety disorder, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9411-9400 (2012). 2. For the period from December 1, 2007, to February 11, 2008, the criteria for an initial evaluation of 100 percent, for a psychiatric disorder, to include PTSD and an anxiety disorder, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9411-9400 (2012). 3. For the period from September 15, 2008, through November 2, 2011, the criteria for an initial evaluation of 70 percent, but no higher, for a psychiatric disorder, to include PTSD and an anxiety disorder, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130, Diagnostic Code 9411-9400. 4. The criteria for an effective date earlier than November 3, 2011, for a total evaluation for a psychiatric disorder, to include PTSD and an anxiety disorder, have not been met. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.159, 3.400(o), 4.1, 4.7, 4.130, DC 9411-9400. 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). 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. Accordingly, 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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 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). Because the October 2008 rating decision granting service connection for PTSD and assigned an effective date all the way back to the initial award for anxiety disorder, the claim is construed as an initial rating appeal. In this regard, the Court has held that once service connection is granted the claim is substantiated, additional notice is not required and 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). Therefore, no further notice is needed under VCAA. The Board finds that the effective date claim should be treated similarly. It is acknowledged that the RO has never expressly adjudicated such claim under the provisions of 38 C.F.R. § 3.400, which governs the assignment of effective dates. However, this is not found to have prejudiced the Veteran here. Indeed, the critical question, with which the Veteran has demonstrated actual knowledge, is whether the criteria for a 100 percent evaluation were satisfied prior to the currently assigned effective date of November 3, 2011. As a matter of course in adjudicating the increased rating claim, this was considered by the RO, who provided reasons and bases for why a rating in excess of 30 percent was not warranted (which, by logical extension, explained why a 100 percent rating was not warranted). Under these circumstances, no additional development is required with respect to the duty to notify. VA also 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(c). 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, the Veteran and his representative's statements, as well as statements from his friend and ex-spouse, in support of the claim are of record. Neither the Veteran nor his attorney asserts that there are additional records to be obtained. In light of these facts, the Board finds VA has fulfilled its duty to assist the Veteran with his claim. 38 C.F.R. § 3.159(c). Hence, the Board may address the merits without prejudice to the Veteran. The Board has reviewed all the evidence in the claims file. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by an appellant or obtained on his behalf be discussed in detail. Rather, the 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). Applicable Law and Regulation 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. 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; 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 disability upon the person's ordinary activity, 38 C.F.R. § 4.10. 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's psychiatric disorder has been evaluated under 38 C.F.R. § 4.130, DC 9411-9400. A hyphenated code is used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation. See 38 C.F.R. § 4.27. DC 9411 is the DC for PTSD, and 9400, generalized anxiety disorder. DCs 9400 and 9411 are governed by a General Rating Formula for Mental Disorders. Under the General Rating Formula, a 30 percent rating is warranted for PTSD 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 (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. 38 C.F.R. § 4.130. 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. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. One factor for consideration 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). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Analysis The Court noted two bases for setting aside the January 2011 Board decision: 1) While the Board did not appear to have considered the symptoms listed in the rating criteria an exhaustive list, the Board failed to address the Veteran's symptoms in the context of his occupational and social impairment caused by his PTSD; and, 2) the Board erroneously noted the absence of suicide ideation during a period in 2006 that was prior to the effective date of the Veteran's award of service connection. Citing Moore v. Nicholson, 555 F.3d 1369, 1373 (Fed. Cir. 2009), the Court cautioned the Board to assess the Veteran's disability in light of its history. In her August 2013 written argument, the Veteran's attorney contends that a 100 percent rating is warranted from the effective date of his grant of service connection, June 29, 2006. Following review of the record, and as will be discussed in detail below, the Board finds that a total rating for the service-connected psychiatric disability is warranted for the period from December 1, 2007, to February 11, 2008. This conclusion is based upon the records accompanying a hospitalization from February 2, 2008 to February 11, 2008. During such hospitalization, the Veteran reported severe symptomatology for a month or two leading up to his admission. Thus, resolving doubt in his favor, the Board will find that the severe symptoms reflected in the hospitalization report were present from December 2007. The Board further finds that, for the periods from June 29, 2006, to December 1, 2007, and from February 11, 2008, to September 15, 2008, a 50 percent evaluation is warranted. Finally, from September 15, 2008 onward, a 70 percent evaluation is deemed to most nearly approximate the Veteran's psychiatric disability picture. Aside from the staged total rating from December 1, 2007, to February 11, 2008, there is no basis for an earlier effective date than November 3, 2011 for the award of a 100 percent rating. Historically, the Veteran entered the VA health system in March 2006. Prior to that time, he had worked various jobs, and had been convicted of possession and distribution of child pornography and served time in prison for that offense. His medical records for the period 2003 to 2004 are significant for complaints of low back pain and heart-related symptoms. A January 2004 private entry noted the Veteran's complaints of chest pain and tingling of the fingers. He reported stress secondary to his job. The entry notes an assessment of anxiety and panic attacks secondary to job-related stress. Upon admission into the VA system, the Veteran was on parole and homeless. The evidence of record shows these were his two primary stressors at the time. His closest friend was his parole officer. The evidence of record demonstrates that, in March 2006, the Veteran was transferred from a private hospital to a VA medical facility for depression and active suicidal ideation, which included a plan to kill himself using carbon monoxide. The records note the Veteran's diagnosis with Klinefelter's Syndrome, which resulted in a double mastectomy while in service. The Veteran reported having experienced an identity crisis for the past 60 years, and that he was chronically unhappy. During the intake interview, he attributed many of his reported personality traits and psychiatric symptoms to his Klinefelter's. As detailed in the March 2006 VA admission report, after his release from confinement six-months earlier, the Veteran had resided alone in a home owned by his sister and brother-in-law. Their agreement was for the Veteran to occupy the premises for six months and then move into his own apartment. The Veteran, however, had not been able to obtain employment, so he had no money for his own place. He reportedly planned to tell his sister via telephone, but decided it would be too distressful. So, he cleaned the house, did all of his laundry, and departed to buy a hose to attach to his exhaust pipe for CO poisoning. He reported his plan to his brother-in-law, who contacted his PCP. The PCP directed the Veteran to a hospital. The Board notes that documentation in the claims file reflects the Veteran was employed at a factory in February 2006. His employer's response to VA notes the Veteran quit because he claimed he could not do the lifting that was part of the job. The Veteran reported a lifelong history of anxiety and depression, which included a suicide attempt at age 15. He also reported on-and-off treatment by multiple private psychiatrists, but he denied any psychiatric hospitalizations. The Veteran denied any hallucinations but endorsed a number of anxiety and depression symptoms. The examiner noted some vague homicide ideation towards the person the Veteran accused of setting him up on the child pornography matter; but he denied any intent to act on it. During the course of the VA inpatient treatment, the Veteran's main goal became admission into a VA program named "King." Admission to the program would provide the Veteran with housing and training. The Veteran's treatment records note his mood swings frequently varied with his assessment of the likelihood of gaining admission to the program. A March 2006 entry noted that the Veteran could be evasive as to matters he reported during group sessions. An April 2006 entry notes the Veteran was accepted into the program, and he was optimistic about the future. The April 2006 discharge diagnosis was major depressive disorder and anxiety disorder NOS. Axis V was assigned GAF 50. In a May 2006 entry, the Veteran reported feeling secure at the VA facility at King and had started to develop plans for the future. He had been compliant with his medications, but still had episodes of daytime anxiety. The examiner noted in parentheses that such episodes were not panic attacks. Mental status examination revealed the Veteran as calm, organized, and in a good mood. While talkative and somewhat tangential, his thoughts were goal directed, and his affect was reactive, appropriate in normal range. The examiner noted no psychotic symptoms or cognitive deficits. There was no suicide or homicide ideation, and insight and judgment were good. The examiner noted the Veteran was doing well, and he needed to continue with his pain clinic intervention. This was the backdrop to the Veteran submitting his claim for service connection in June 2006. A July 2006 VA entry notes the Veteran placed himself in a victimized position unless people were especially nice to him. An August 2006 entry notes the absence of psychotic symptoms or suicide or homicide ideation. In an October 2006 statement, the Veteran's former wife described his in-service struggles due to his Klinefelter's. She related several instances that indicated the intense anger he harbored. In November 2006, the Veteran underwent a VA psychiatric examination. He had been married and divorced twice, and had a son from his first marriage. He was vague about his post-service employment history, had what sounded like a sales position prior to his arrest and subsequent incarceration. The Veteran denied having any supportive social relationships. During the interview, he was dressed appropriately and hygiene did not appear to be a problem. He denied any mood or thought disorder, or suicidal or homicidal ideation. He was not shown to have any overt problems with his memory, reasoning, basic judgment or fund of knowledge throughout the examination. He took a MCMI-III diagnostic test, which demonstrated some symptom magnification tendencies. Nonetheless, the examiner noted the test disclosed a moderate degree of overall psychopathology that would manifest itself in everyday situations, which was confirmed by other treatment records. The examiner concluded that the Veteran had PTSD due to the harassment and sexual trauma in service, which was manifested by intrusive recollections and repression of the humiliation of those incidents. The harassment was related to the Veteran's physical appearance due to his Klinefelter's Syndrome. The Veteran also had persistent avoidance of those feelings and had used drugs in the past to mask those feelings. He did not have any trusting social relationships and had many angry defenses to protect himself from further pain. He reported nightmares, along with ongoing irritability and anger. The Veteran's GAF score related solely to his PTSD was 70. As the outpatient entries noted earlier show, the Veteran was functioning well within the VA program designed to help him become economically self-sufficient. A November 2006 VA entry notes the Veteran believed the Compensation and Pension examination accurately presented his traumas and symptoms. In January 2007, the VA examiner clarified his opinion and diagnosed the Veteran with an anxiety disorder related to his harassment in service and PTSD as due to the military sexual trauma in service. Both were eventually service connected. The examiner opined the Veteran's symptomatology was mild and amenable to outpatient treatment. The examiner opined further that the Veteran was not shown to be precluded from employment or basic everyday functioning as a result of his psychiatric disorders. In February 2007, the Veteran reported that he was raped in the shower while on active duty. He also reported his son was the product of artificial insemination of the Veteran's wife with the sperm of an anonymous donor. He had long-term anxiety over the deception, as his son did not know. At this point in time, the Veteran's claim had not been granted. A May 2007 entry notes that the Veteran was concerned with the claim, and he reported his long-term plan was to live on VA disability. In July 2007, the Veteran was shown to demonstrate mood instability, lability and irritability. He also reported flashbacks, nightmares and other sleep impairment problems throughout that period of time, as noted in August 2007. The Veteran's attorney asserts that the Veteran's above-reported symptoms show his total impairment. However, as of October 2007, the Veteran was attending school. An October 2007 treatment report notes intrusive PTSD symptoms, but the Veteran reported they did not get in the way of his school performance. In November 2007, the examiner noted the Veteran was doing well in school and intended to double his course load the following semester. His mental status was good. Thus, from June 29, 2006 through November 30, 2007, the Board finds that the Veteran's psychiatric disorder most nearly approximates a 50-percent rating. Indeed, during this period, the Veteran's symptoms included depression, intrusive thoughts, sleep impairment including due to nightmares, anxiety, and irritability. Overall then, the record establishes disturbances in motivation in mood that resulted in reduced reliability and productivity and caused difficulty in establishing and maintaining effective relationships. Such evidence does not indicate occupational and social impairment with deficiencies in most areas. Rather, the record reflects that the Veteran was generally having success as a student and was planning to increase his course load the following semester. His cognitive abilities and speech were not impaired. His anger did hinder his relationships with people, but again, this did not impede his school life except to the extent already reflected by the 50 percent evaluation awarded in the instant decision. Moreover, he was compliant with the terms of his probation, further indicating an ability to follow the rules and respect authority. He also indicated in October 2007 that he had gone on a fishing trip with some friends and enjoyed himself, further evidencing some level of social interaction and connectedness with others beyond his wife. Further in this regard, he maintained contact with two sisters. The Board has also considered the GAF scores of record. During the period in question, the Veteran's GAF scores ranged from 50 to 70. While the score of 50 is indicative of serious symptoms, this score is not deemed to mirror the actual reported symptoms noted in the treatment records. Aside from a history of suicidal attempt that occurred prior to the rating period in question, the remaining criteria commensurate with a GAF of 50 were not shown. For example, there were no severe obsessional rituals and no serious impairment in social and school functioning. Again, the Veteran's scholastic achievements appear to have been at least satisfactory and there is enough evidence of social involvement to conclude that his functioning in this regard was only moderately impaired. For these reasons, the GAF of 50, in and of itself, does not persuade the Board that an evaluation in excess of 50 percent is warranted for any portion of the rating period in question. As alluded to earlier, from December 1, 2007 to February 11, 2008, the Board will resolve any doubt in the Veteran's favor and assign a 100 percent evaluation based on evidence of greatly increased symptoms around the time of his VA hospitalization from February 2, 2008, to December 11, 2008. Indeed, his GAF score on admission was 40, representing heightened symptomatology. Per the history listed in the admission report, the Veteran had, for the past two months experienced increased symptoms and believed that his medications were no longer effective. He reported loss of energy and appetite, and had allegedly lost 25 pounds. His sleep was also consistently disturbed, with him only getting 2-3 hours of sleep at a time. He also endorsed passive suicidal ideation over this period. According to December 2007 VA outpatient records, he was also struggling with the stressors associated with school during this period, though there was no indication that he was slipping in his academics. Finally, he had become noncompliant with his medications. For all of these reasons, the Board will assign a total rating for this time period. From February 11, 2008, the Veteran's symptoms appear to have quieted down to their prior levels. Indeed, his inpatient discharge report reflects a GAF of 55, as compared to 40 upon admission. Moreover, VA treatment up to September 15, 2008 generally demonstrates symptomatology similar to that shown prior to his February 2008 hospitalization. Indeed, an April 2008 treatment report indicated that the Veteran's mental health was unremarkable. He was in a good mood and his insight and judgment were good. While he endorsed panic attacks, these were attributed to his use of prednisone and not to his psychiatric disability. A subsequent July 2008 report noted a GAF score of 55. Overall then, there is no evidence to suggest that, for the period from February 11, 2008 to September 15, 2008, a rating in excess of 50 percent is warranted. There is no indication that his school work or his level of social interaction were significantly different from that demonstrated prior to his flare of mental symptoms that started in December 2007. Rather, the period from December 1, 2007, to February 11, 2008, is interpreted as an interruption from the level of functioning demonstrated prior to that time, and, without clear evidence to the contrary, the Board finds no support for a rating in excess of 50 percent once the Veteran completed his hospital stay on February 11, 2008. Finally, for the period beginning September 15, 2008, the Board finds that a 70 percent rating is warranted for the Veteran's service-connected psychiatric disability. A September 2008 mental health entry notes the Veteran was taking prednisone, and he had little social support. He was administered a Suicide Assessment which revealed he was a low suicide risk. The only positive answer the Veteran provided was that he had a past suicide attempt. Axis IV of the assessment notes the Veteran was still unemployed, his housing was unstable, and he still was on probation. The Veteran reported sporadic forgetfulness for names and incidental things, but he participated in class and did his homework and other memory-based work well. He reported his sleep was generally at baseline, but for two months or more, he had experienced restless legs once or twice a week. The examiner noted the Veteran attended therapy and met other obligations of his parole, and his compliance with his medications was good. Mental status examination was unremarkable. The examiner noted the Veteran was in a good mood, his affect elevated, and there were no psychotic symptoms, restlessness, or paranoia. Speech was not pressured; and, thought were organized and goal directed, but a little flighty. Insight and judgment were good. The examiner opined the Veteran appeared stable, and that the Prednisone may have been causing some of his mild memory deficits. The examiner noted further that the Veteran gave a rather good description of restless leg syndrome. Axis V GAF was assessed at 55. The Veteran underwent another VA examination on September 15, 2008. The examiner noted the Veteran's hospitalization in March 2006, as well as the two prior VA examiner's opinions in November 2006 and January 2007. The Veteran reported being depressed and anxious his whole life, and stated that he had two suicide attempts when he was age 15. The Veteran reported at this time that he had a "lot of forgetfulness, short term memory, rare nightmares, [and] a lot of panic attacks. [He] thought of the rape [any time] his rear end hurt." The Veteran's symptomatology was noted as being mild to moderate in severity, and he had remissions that lasted up to one or two days. The Veteran reported that he was unable to work because of his rheumatoid arthritis. He had been married and divorced twice and had a son from the first marriage, with whom he has a distant relationship. The Veteran generally stayed at home during the day, though he had one or two friends and that he had been fishing and in contact with two of his sisters. The Veteran kept up with routine responsibilities of self care, but had a limited role in family functioning and had somewhat limited social and interpersonal relationships and recreational and leisure pursuits. On examination, there was no impairment in thought process or communication, or any delusions or hallucinations during the interview. The Veteran had good eye contact and interaction, though he was somewhat dramatic. He stated that he had suicidal thoughts "all the time," though he denied suicidal ideations, plan or intent, or homicidal ideations. He was able to maintain minimal personal hygiene and other basic activities of daily living, though he stated that he infrequently bathed because he had "no reason to." He was oriented to person, time and place but had some short-term memory problems. Additionally, he endorsed obsessive and ritualistic behaviors, which included locking doors and checking the windows of his house. His speech rate was normal. He reported severe panic attacks occurring three to four times a week. Such attacks led him to stay in his house, though the examiner noted that the Veteran appeared to still be able to go out of the house despite the ongoing panic attacks. The Veteran endorsed symptoms of depression and low energy, stating he preferred to either sleep or to just sit there. He denied any impulse control problems, though he endorsed sleeping eleven to twelve hours a night and taking a several-hour nap during the day. The VA examiner rendered a diagnosis of chronic moderate PTSD and assigned a GAF score of 55. The VA examiner also related the Veteran's panic attacks to the service-connected anxiety disorder. The examiner further concluded that the cause of the Veteran's lack of employment at that time was rheumatoid arthritis and not any mental disorder. The examiner specifically stated that the Veteran's psychiatric disorder would only pose "mild to moderate vocational limitations." The foregoing evidence supports a 70 percent rating for the period in question. Indeed, at the VA examination on September 15, 2008, the Veteran endorsed suicidal thoughts and obsessional and ritualistic behavior. He also indicated some problems with neglect of personal appearance and hygiene at this time. Further, the examiner noted the Veteran's panic attacks, which began occurring three to four times a week, were related to his anxiety disorder at that time, and not to his use of prednisone. Moreover, shortly thereafter, he began experiencing visual hallucinations and spatial disorientation in December 2008. At that time, he also manifested severe suicidal ideations. Thus, his disability picture more closely approximates a 70-percent rating beginning September 15, 2008. The Board finds that the next-higher 100 percent rating was not met or approximated as of September 15, 2008, as the Veteran's impairment was not total. Rather, he did maintain minimal independence in his functioning, to include having at least two friends and maintaining some contact with siblings. The Board notes that, while he was hospitalized again for approximately three days in December 2008, his impairment was not total. Upon admission, the Veteran reported visual hallucinations while driving himself to the hospital. The examiner noted the Veteran's sleep deprivation and stress. Although he denied active suicide ideation, the examiner noted passive suicide ideation was present. The Veteran provided conflicting reports of his symptoms, and he was vague as to the nature of his reported visual hallucinations. An examiner in the emergency department noted the Veteran was difficult to interview. He was evasive when asked if he had plans to harm himself, and he said repeatedly it would be a good idea if he was admitted. The examiner noted the Veteran was overwhelmed. The Veteran denied any other psychotic symptoms, but he did endorse depressed mood due to increasing physical distress over the prior few weeks. He reported that he liked living alone and having his freedom, and he enjoyed his new living arrangements. The Veteran described sporadic, rather concrete and specific visual hallucinations not connected to underlying anxieties or delusions; and, the Veteran gave no evidence of cognitive disturbances. Speech and thought patterns were organized and goal directed. The Veteran did not have specific hypochondrical beliefs. The examiner noted the visual hallucinations suggested an organic process, including simply sleep deprivation and stress; but it could also relate to some occult process, perhaps involving the Veteran's arthritic condition or an autoimmune disorder. Atypical migraine was also a possibility. The Veteran was admitted with suicide ideation in the context of significant pain. He had complained of lower extremity edema and physical pain. By the next day, the Veteran's mood improved as his pain improved. The Veteran's December 2008 records show his hospitalization was triggered primarily by his physical ailments rather than his mental disorder symptomatology. Those entries indicate the Veteran had transitioned to communal living, which is evidence his service-connected symptomatology had not totally impaired his functioning. His subsequent therapy records in fact show that to be the case. Thus, the hospitalization is distinguishable from the one that had occurred in February 2008, both in length and in the nature of the overall disability picture shown on each occasion. In January 2009, the Veteran reported minimal symptoms of PTSD and depression. He liked his new low-income apartment, and he enjoyed the town he lived in. He reported that his sleep, appetite, level of energy, and outlook were good. Additionally, he was taking his medications in an orderly way. He also reported that he was interested in dating, though he was not yet involved with anyone. Further, the Veteran was no longer on parole. Mental status examination was remarkable for good mood, good grooming, including dyed hair, and good affect. This continued to be the case throughout 2009. In April 2009, the Veteran reported that he was working at establishing a better relationship with his son, and he had made a couple of friends. By August 2009, the Veteran reported he was considering moving in with a woman and her three children. He was still coping with physical pain and weight gain due to the Prednisone, but he reported stable psychiatric symptoms. An October 2009 entry notes the Veteran's potential plans with the woman did not end on a positive note. Although he reported he spent a lot of money during the situation, he admitted he "screwed up big-time," but it did not impact his symptoms or impairment. His pain and weight were stable, and he had enrolled in a water exercise program. The examiner noted the Veteran did not report any new symptoms, and he was not distressed by his parents' illness. In March 2010, the Veteran described his baseline symptoms of depression as being minimal. His sleep, energy level, and appetite were all okay. In VA records dated in July 2010, November 2010, and July 2011, he denied suicidal thoughts. His GAF was a 60 on those occasions, though he did endorse low mood and high stress levels in July 2010. Another record dated that same month indicated good sleep and social activity. An October 2011 outpatient record indicated a GAF score of 55. The foregoing evidence fails to demonstrate total social and occupational impairment. In fact, in many of these reports the GAF score is indicate of more moderate symptoms. At no time during this period is there clear evidence of a complete lack of functioning. Rather, some evidence arguably indicates actual interpersonal growth, as the Veteran was trying to improve his relationship with his son and had plans to move in with a girlfriend. Thus, while the overall disability picture from September 15, 2008 to November 3, 2011, warrants assignment of a 70 percent rating, the weight of the evidence does not establish entitlement to a total 100 percent evaluation. As explained in the course of the above discussion, the weight of the evidence prior to November 3, 2011, is against a finding of total social and occupational impairment (except for the period from December 1, 2007, to February 11, 2008, in which the instant decision does award such total rating). In general, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. As this is an appeal of an initial rating, this case is construed as an original claim. Such claim was received on June 29, 2006. As discussed in great detail above, the first date that total occupational and social impairment was demonstrated in the record (aside from the staged rating already awarded from December 1, 2007 to February 11, 2008) is September 15, 2008. Despite the contentions from the Veteran and his attorney, the weight of the evidence supports no more than a 50 percent evaluation for the periods from June 29, 2006, to December 1, 2007, and from February 11, 2008, to September 15, 2008, and no more than a 70 percent rating from September 15, 2008, to November 2, 2011, for the reasons already explained in detail above. Moreover, it is not necessary to consider whether any earlier documents of record constitute informal claims under either 38 C.F.R. § 3.155 or 3.157, because, even if an earlier date of claim is established, the later date between the date of claim and date entitlement arose is the date that controls under 38 C.F.R. § 3.400. Thus, the claim for an earlier effective date must fail. The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." See 38 C.F.R. § 3.321(b)(1). 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. See 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 and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, 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. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected psychiatric disorder, to include PTSD and an anxiety disorder. Hence, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's psychiatric disorder. This means the disability picture of the Veteran's service-connected psychiatric disorder, to include PTSD and an anxiety disorder, is not exceptional; and, the first requirement of the Thun analysis process is not met. Moreover, as discussed in detail earlier, the medical evidence reflects the more severe manifestations that would warrant a higher rating of the disorder are not present in this case. As the rating schedule is adequate to evaluate the disability and the Veteran's average impairment in earning capacity to the extent practical, see 38 C.F.R. § 4.1, the evidence of record shows a factual basis for referral for extraschedular consideration is not present. 38 C.F.R. § 3.321(b)(1). In reaching the above determinations, the Board has appropriately applied the benefit of the doubt doctrine. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App 49 (1990). ORDER For the period from June 29, 2006 to December 1, 2007, and from February 11, 2008, to September 15, 2008, an initial evaluation of 50 percent for a psychiatric disorder, to include PTSD and an anxiety disorder, is granted. For the period from December 1, 2007, to February 11, 2008, an initial evaluation of 100 percent for a psychiatric disorder, to include PTSD and an anxiety disorder is granted. For the period from September 15, 2008, through November 2, 2011, an initial evaluation of 70 percent for a psychiatric disorder, to include PTSD and an anxiety disorder is granted. Entitlement to an effective date earlier than November 3, 2011, for a 100 percent evaluation for a psychiatric disorder, to include PTSD and an anxiety disorder is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs