Citation Nr: 1338360 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 08-19 796 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon THE ISSUE Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) prior to June 8, 2011. REPRESENTATION Appellant represented by: Mary Ann Royle, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from January 1967 to September 1969. This appeal to the Board of Veterans' Appeals (Board) arose from an August 2006 rating decision in which the RO, inter alia, granted service connection and assigned an initial, 10 percent disability rating for PTSD, effective March 30, 2006 (the date of the claim for service connection). In March 2007, the Veteran filed a notice of disagreement (NOD) with the initial rating assigned, and the RO issued a statement of the case (SOC) in May 2008. The Veteran filed a substantive appeal (via a VA Form 9, Appeal to Board of Veterans' Appeals) in June 2008. Because the appeal emanated from the Veteran's disagreement with the initial rating assigned following the award of service connection for PTSD, the Board characterized this matter in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). In an April 2008 rating decision, the RO granted a 30 percent rating for PTSD, effective March 30, 2006. In a June 2009 rating decision, the RO granted a 50 percent rating for PTSD, effective March 17, 2009 (the date of a VA examination). In June 2010, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO; a transcript of that hearing is of record. In November 2010, the undersigned Veteran's Law Judge granted the Veteran's motion to advance this appeal on the Board's docket, pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2002) and 38 C.F.R. § 20.900(c) (2010). In December 2010, the Board in part denied an initial rating in excess of 30 percent prior to March 17, 2009 and remanded the issues of a rating in excess of 50 percent from March 2009 and a total rating based on individual unemployability (TDIU) for further development. The Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court). In June 2011, the Court vacated and remanded the decision on a rating in excess of 30 percent prior to March 17, 2009 for compliance with the instructions in a joint motion submitted by representatives of both parties. In a June 2011 rating decision, the RO granted higher ratings for PTSD: 70 percent, effective January 12, 2011, 100 percent, effective June 8, 2011. The RO also awarded a TDIU, effective March 7, 2011. In September 2011, the Board again remanded the appeal to obtain potentially relevant records identified by the Veteran. In an August 2013 rating decision, the RO awarded an initial, 70 percent rating from March 30, 2006, continued the 100 percent rating effective June 8, 2011, and granted a TDIU, effective March 30, 2006. As indicated, the Veteran has been granted a TDIU (due to PTSD) from the March 30, 2006 effective date of the award of service connection, and the maximum, 100 percent schedular rating for PTSD from June 28, 2011. Accordingly, on these facts, the only matter remaining before the Board is that set forth on the title page. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). A review of the Virtual VA and Veterans Benefits Management System paperless claims files does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim herein decided have been accomplished. 2. From the March 30, 2006 effective date of the award of service connection to January 12, 2011, the Veteran's PTSD was manifested by such symptoms as intrusive thoughts of his combat experiences, nightmares, hypervigilance, exaggerated startle response, avoidance activities, irritability, lack of concentration and some social isolation; collectively, these symptoms are indicative of no more than occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood with suicidal ideation. 3. Competent evidence suggests that, as of January 12, 2011, the Veteran's PTSD has been manifested by such symptoms as the continuation of the combat-related and avoidance symptoms, and by such symptoms as gross impairment in thought processes or communication and persistent delusions or hallucinations that impaired function; grossly inappropriate behavior; and the appearance of persistent danger of hurting self or others; overall, these symptoms are indicative of total occupational and social impairment. 4. The applicable rating criteria are adequate to rate the Veteran's PTSD at all times pertinent to this appeal. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 70 percent for PTSD, prior to January 12, 2011, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2013). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for a 100 percent for PTSD, from January 12, 2011, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, a May 2006 pre-rating letter provided the Veteran with information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. The August 2006 rating decision reflects the RO's initial adjudication of the claim after issuance of the May 2006 letter. Post rating, the May 2008 SOC, along with a December 2008 letter, set forth the criteria for higher ratings for PTSD. The Board acknowledges that the Veteran was not told what the evidence must specifically show to substantiate a claim for a higher initial rating for a psychiatric disorder. However, to whatever extent the aforementioned letters and SOC are deficient in meeting the VCAA requirements, the Board notes that the claims file reflects that the Veteran and his attorney had actual knowledge of the information and evidence necessary to substantiate his claim for a higher initial rating. Through testimony during the June 2010 Board hearing and in various lay statements, the Veteran has made clear that he understands that higher ratings are available based on increasing symptomatology and functional impairment. Given the Veteran's statements, the Board finds that any error in notice regarding substantiating the claim for a higher initial rating is harmless because actual knowledge of what the evidence must show to substantiate the claim is shown. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of the Veteran's VA outpatient clinic, Vet Center, and hospital treatment records, letters from a private mental health provider and from a private consulting psychologist, and reports of VA psychiatric examinations in June 2006, March 2009, and June 2011. Also of record and considered in connection with the appeal is the transcript of the Veteran's June 2010 Board hearing, along with written statements provided by the Veteran and by various individuals on his behalf, including his current attorney. . The Board finds that no further RO action in this appeal, prior to appellate consideration, is required. With respect to the Board hearing, it is noted that, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims held that 38 C.F.R. 3.103(c)(2) requires that a Veterans Law Judge (VLJ) who chairs a hearing must fulfill two duties: (1) to fully explain the issues and (2) to suggest the submission of evidence that may have been overlooked. Here, the hearing focused on the elements necessary to substantiate the claim for an increased rating including the nature, frequency, and severity of his symptoms and their impact on his occupation and social relationships. The Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claim and accepted additional evidence with a waiver of consideration by the RO. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor has identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2), and that the hearing is legally sufficient. The Board also notes that, in a July 2011 statement, the Veteran's representative reported that the Veteran was receiving disability benefits from the Social Security Administration (SSA). However, in response to an inquiry by the RO, in January 2012 SSA reported that no medical records were held because either the Veteran had not filed a claim or because no medical records were obtained. As such, no further RO action in this regard is warranted. In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Background The Veteran served as a U.S. Army infantryman and paratrooper with service in the Republic of Vietnam. He was awarded the Combat Infantryman's Badge. He contends that his symptoms of PTSD have been severe since his combat service and are more severe than was contemplated in the initial, 70 percent rating assigned from the March 30, 2006 effective date of the award of service connection to the June 8, 2011 effective date of the award of a 100 percent rating. As the Veteran and other lay observers reported that the Veteran displayed symptoms of severe PTSD prior to March 2006, the Board reviewed and will briefly summarize the earlier lay and medical evidence. Service treatment records are silent for any mental health treatment, although the Veteran reported recurring nightmares on the medical history questionnaire completed in September 1968, in conjunction with his discharge physical examination, following his return from nearly a year of combat service. In October 1970, the Veteran was committed for mental health treatment at a state hospital because of his unusual behavior at the scene of an automobile accident. The attending physician noted that the Veteran had completed a General Education Development test but had difficulty holding a steady job. The Veteran also reported abuse of drugs and alcohol. There was no mention of traumatic events in combat, and the physician noted that the Veteran was "... able to quickly learn the play the game of giving the right answer without really getting down to the cause of his difficulties." The physician diagnosed psychosis associated with drug intoxication and schizophrenia, latent type. In 1981, the Veteran was examined by a private physician and by a VA social worker and psychiatrist. In a letter to an attorney, the private physician noted that the Veteran had been in multiple automobile accidents and was charged with driving while intoxicated. The physician noted that the Veteran was in fear of his own safety, had nightmares of his war experiences, and was engaging in self-destructive behavior including substance abuse. He noted, "Psychologically, this man is still in Vietnam fighting the war and frequently getting close to getting killed." The physician diagnosed subconscious war neurosis and recommended hypnotherapy. A VA social worker noted that the Veteran was employed after service in construction and road paving work and operated his own business for two to three years that was not financially successful. The Veteran reported that he had written a book and had done some inventing and gold prospecting. However, he had no source of income and was supported by a girlfriend with some close relationships with family. The social worker noted the Veteran's reports of two previous suicide attempts, past delusional thoughts, and current behaviors such as hypervigilance and fear of crowds. The Veteran continued to abuse marijuana but abandoned alcohol as a result of the hypnotherapy. The VA psychiatrist noted a similar history and current symptoms and concluded that the Veteran was unsuccessful in adjusting to civilian life after the war complicated by immaturity and a vicious cycle of substance abuse. The psychiatrist diagnosed post-Vietnam stress syndrome, cannabis abuse, histrionic personality disorder, psychosocial pressures of unemployment and alienation. The psychiatrist did not assign a GAF score but concluded that the Veteran's status was "poor with marked impairment in social relations and occupational functioning." In 1984, the private physician wrote to the VA social worker recounting similar symptoms of recurrent memories, guilt, hypervigilance, and destructive behavior involving vehicles and substance abuse. The physician noted that the Veteran participated in hypnotherapy for only a short time and had not been seen since 1981. The claims file does not contain lay or medical evidence dated from 1984 to March 2006 when the RO received the Veteran's claim for service connection for PTSD. However, lay statements and publically available state corporation records showed that the Veteran operated several trucking, paving, and construction businesses from 1988 through 2010. The Veteran sought counseling at a Vet Center from April 2006 to August 2006. The Veteran submitted poetry and excerpts from his autobiographical book describing his combat experiences and feelings. The writings included descriptions of traumatic events in combat that are articulate and well written without grammatical errors or rambling thoughts. A counselor noted that the Veteran attributed his survival of combat to his attitude that he was a "dead man walking" and thus had no fear. He reported two marriages after service, the most recent intact for the last 16 years with no children. He reported symptoms of hypervigilance, keeping firearms available in the home, and avoidance of movies. He described himself as a successful businessman in the past but experienced some recent depression that was treated using naturalist techniques. He discussed his views on good and evil in the world and commented that he sent funds to his wife's family in Asia as a form of reparations for his actions in combat. The counselor noted that the Veteran seemed to have clear occupational plans but his expectations were grandiose and optimistic. In August 2006, the Veteran reported that he had been "cured by work" and terminated the counseling sessions. In June 2006, a VA psychologist noted a review of the claims file, summarized the Veteran's reports of his history and symptoms, and performed a mental status examination. The Veteran reported having a short-attention span and guilt over actions taken in Vietnam. He was dressed in clean, casual clothing. His intellect appeared to be above the average range and cognitive functioning appeared grossly intact. He was alert and oriented with no signs of psychosis. He denied suicidal and homicidal ideation. He showed signs of emotional and psychological reactivity while describing Vietnam experiences. Affect was appropriate to topics of conversation and his mood appeared euthymic. The Veteran reported that he and his wife got along well. Although he experienced emotional and psychological reactions due to triggers and displayed avoidance behavior, he reported that he focused on controlling his temper. He worked as a self-employed contractor and had 27 employees up until 1993 when he bankrupted the company after buying an ill-fated rock quarry. He said that he continued to work as a heavy equipment operator and contractor in an effort to pay off his debts, but had trouble locating work because he lost his contractor's license because of the bankruptcy. He was able to drive a vehicle and work when he could find a customer. He said that during the last 6 months, he generally worked one week per month. He suggested that he got along reasonably well with his peers and customers. The Veteran reported current symptoms of nightmares, intrusive thoughts, and emotional and psychological reactivity to specific triggers. He said he avoided conversations, people, places and events that reminded him of PTSD. He said he focused on controlling his temper and was generally able to do so, but said that he had broken objects in the past when frustrated. He also described hypervigilant behavior and complained of concentration difficulties and exaggerated startle response. He said it was difficult for him to feel close to those outside his family. He reported that he had been sober since 1997 and that prior to that he drank alcohol daily. He also had a history of polysubstance abuse. The examiner's diagnostic impression was PTSD and polysubstance dependence in remission. The examiner assigned a GAF score of 62 indicating some mild symptoms or difficulty in occupational and social functioning but generally functioning well with some meaningful social relationships. In June 2008, the Veteran submitted a lengthy statement with his substantive appeal. He described some of his combat experiences and the symptoms and behaviors in the 1970s and 1980s that included several suicide attempts, the most recent in 1997. He addressed several factors in the General Rating Formula for Mental Disorders. He explained his views of good, evil, and various religious thoughts. He referred to events in the 1970s and 1980s as they related to inappropriate and self destructive behavior. He denied any inability to perform daily hygiene, abuse of substances, disorientation, or memory loss except for "the usual forgetful memory which comes with age." He noted that he had difficulty finishing the final 90 to 95 percent of projects and could not sit through educational sessions. He reported that everyone in his family liked him but that his judgment in financial matters was deficient. He further noted that when depressed, suicidal thoughts are always his first answer. In March 2009, another VA psychologist noted a review of the claims file. The Veteran reported that he continued to own his small business but was experiencing nightmares and recurrent thoughts of combat, hypervigilance (carried firearms in the home), startle response, difficulty with relationships, anger control, sleep, and concentration. He also experienced depression, lack of motivation, and thoughts of worthlessness and suicide but no attempts since 1997. He reported that he avoids crowds and did not answer a visitor at the front door but rather confronted the visitor from behind. He reported that his marriage was failing because he was not willing to engage in social activities. However, the Veteran reported that he was able to work and write books and a screen plan. He reported that he had concentration problems on the job but got along well with coworkers and customers. The only treatment or therapy was the brief VA treatment sessions in 2006. On examination, the psychologist noted no hygiene, orientation, or cognitive impairments and no hallucinations or delusions. The Veteran had a wide range of affect but did not discuss his past religious thoughts. The psychologist diagnosed PTSD and secondary depression, all associated with the combat traumas. The psychologist assigned a GAF score of 46 as the highest in the past year, indicating serious social and occupational impairment. In a statement in August 2009, the Veteran noted that his symptoms had become more severe and that he could not function in daily life. He noted recurrent suicidal thoughts, described his behavior as erratic, and reported that relationships with other people including his wife had ended. During the June 2010 Board hearing, the Veteran testified that the last time his business had full time work was in 2003. Thereafter, his paving company had work about 30 days per year. He was able to work only several days per month but could work 10 hours per day if he had a customer. He stated that the problem was not the economy because his competitors were doing fine; rather, he attributed the lack of business to his recurrent guilt and memories of Vietnam, depression, and subconscious eccentric religious thoughts. He stated that he had been separated from his wife for two years and rarely left his home except for shopping some family events. He stated that he spent his time writing books and had not sought or participated in any form of treatment. He reported one panic attack in the past and feelings of hopelessness and suicidal ideations but no plan or recent attempts. The Veteran submitted three statements from his mother, wife, and former bookkeeper, which each noted that the Veteran lived alone, separated from his wife, and rarely worked or left the home. All were in fear of his possession of firearms and possibility of suicide. The Veteran's wife attributed his financial difficulties as caused by poor business management including an inability to properly bid on a job and focus on the work to completion. The bookkeeper noted that the Veteran spent money erratically, had episodes of anger and irritability, and talked about religion in strange ways. In a September 2010 brief, the Veteran's attorney argued that the Veteran should be rated as 70 or 100 percent disabled and assigned a TDIU, citing symptoms such as suicidal ideation, illogical speech, and persistent danger to himself or others. The representative called attention to the Veteran's lack of work, lack of motivation, and poor business judgment as indications of unemployability. The representative further contended that the effective date for higher ratings should be much earlier, citing evidence since the 1980s. In March 2011, the representative submitted the Veteran's small business tax returns for 2009 and 2010 that showed very modest gross receipts representing some work performed but expenses that exceeded receipts so that the business was operating at a small loss. In January 2011, the Veteran sought VA outpatient treatment on the advice of his representative but was admitted to a VA hospital for expressions of suicidal ideations and intent to "treat all people as mass murderers until I know better." The attending psychiatrist noted that there were no medical records available for the Veteran's history but substantially summarized the history based on the Veteran's and his sister's reports. The attending physician noted that the Veteran provided excerpts from his books that exhibited delusional thoughts. At one point, the Veteran reported that he had good relationships with his wife and business partners and was working 72 hours per week. The Veteran's sister's reported that "...he has been like this since returning from Vietnam." The psychiatrist recorded detailed statements by the Veteran that he evaluated as entrenched delusional symptoms and flights of ideas with a belief that his subconscious was making him suicidal. The psychiatrist diagnosed psychotic and mood disorders and PTSD with possible bipolar disorder. The psychiatrist evaluated the current disturbances as a manic episode and that the role of his PTSD in this episode was unclear. The psychiatrist assigned a GAF of 30, indicating behavior considerably influenced by delusions or an inability to function in almost all areas. Several inpatient evaluations by different psychiatrists contained similar symptoms and evaluations. The Veteran was discharged from the hospital after two days and later declined to make follow-up appointments. At the time of hospital discharge, the attending psychiatrist noted that the symptoms were stable but not much reduced and assigned a GAF score of 35. In conjunction with a June 2011 examination, a VA psychologist noted a review of the claims file and accurately summarized the history including the manic episode for which the Veteran was hospitalized in January. The psychologist noted that the Veteran was rambling, circumstantial, and appeared delusional in his current examination. The Veteran reported that he was reclusive and had not worked since December 2010 and had difficulty focusing on bids and inhibiting his desires to talk about his subconscious struggles. The psychologist noted that the Veteran's hygiene was fair, orientation intact, and that his speech was clear in articulation but illogical, incoherent, delusional, and grandiose with disrupted attention and concentration. The Veteran reported that he was able to live alone, dress, and cook but was in arrears of paying some bills, suggesting that he was not able to manage his own financial affairs. The psychologist assigned a GAF of 40 indicating impairment in reality testing and communications and major impairment in several areas. In a July 2011 brief, the Veteran's attorney argued that the record showed suicidal ideations during the period remaining under consideration, and references to earlier suicidal attempts. The attorney noted that the Vet Center counselor referred to the Veteran's statements of "walking like a dead man." However, the Veteran has only expressed this as his means of coping with combat stress during service and not a current symptom. The attorney appears to have misquoted statements offered by the Veteran in 2006 as reflecting homicidal ideation ("treat everyone as a mass murderer") rather than an expression of hypervigilance ("...treat everyone as if they are going to kick in the door and kill me"). The former statements were not noted until the January 2011 hospital admission for a manic episode. The attorney accurately noted that clinicians found the Veteran's statements regarding his business prospects as grandiose and optimistic. The attorney also called attention to the 1981, 2009, and 2011 examinations as evidence of a continuous degree of serious impairment and contended that the Veteran's failing businesses were evidence of unemployability. In response to the RO's proposal that the Veteran was incompetent to handle his own funds, the Veteran submitted his own statement, as well as statements from his mother and bookkeeper. The Veteran noted that once he began receiving compensation for TDIU, he was able to manage his personal finances, noting that the problem was a lack of income and not responsibility. He continued to own and presumably drive an automobile. The bookkeeper also reported that his financial distress was caused by insufficient income from lack of work and not because of irresponsible or erratic money decisions. The Veteran's mother reported that she had a very close relationship with the Veteran and spoke on the telephone on a regular basis. In May 2013, the Veteran's attorney submitted a report of a record review by a private psychologist who provided a detailed commentary on the medical history since 1981 and concluded that the Veteran had severe impairment of social and occupational function since the 1980s and at least since 2006 and was unemployable since March 2006. The psychologist quoted extensively from the various reports discussed above and discounted the conclusions of the VA examiner in March 2006 as based on an incomplete history and expression of symptoms later refuted by the Veteran's relatives. III. Analysis Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. As noted, the RO has already assigned staged ratings for the Veteran's PTSD, and only the matter of the Veteran's entitlement to an initial rating in excess of 70 percent for the period prior to June 8, 2011 remains before the Board. However, the Board will consider the propriety of the assigned rating, as well as whether staged rating of the Veteran's PTSD, prior to June 8, 2011, is warranted. The ratings for the Veteran's PTSD have been assigned pursuant to DC 9411. However, the actual criteria for evaluating psychiatric disabilities other than eating disorders are set forth in a general rating formula. See 38 C.F.R. § 4.130. A 70 percent rating is assigned 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. A 100 percent rating is assigned 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; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The symptoms and manifestations listed under the above rating formula are not requirements for a particular evaluation, but are examples providing guidance as to the type and degree of severity of these symptoms. Consideration also must be given to factors outside the rating criteria in determining the level of occupational and social impairment. The Board will not require the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for PTSD. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The evaluation of evidence generally involves a three step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Then, the Board must determine whether the evidence is credible. The Board must make an express credibility finding regarding lay evidence. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Finally, the Board must weigh the probative value of the proffered evidence in light of the entirety of the record. Considering the pertinent evidence in light of the above, the Board finds that, although an initial rating in excess of 70 percent for PTSD is not warranted prior to the January 12, 2011date of admission to a VA hospital for psychiatric, with resolution of all reasonable doubt in the Veteran's favor, the 100 percent rating for his PTSD is warranted as of the date of that hospitalization. Before assessing the competence, credibility, and probative weight to be assigned to individual evidence, the Board will address two overarching contentions. First, the Board does not find that the degree of severity of the Veteran's symptoms observed in 1981 existed throughout the history as contended by the Veteran, his family, and the consulting psychologist. The Veteran's reports of his combat experiences are credible as they are consistent with the nature and circumstances of his duties and were generally accepted by examiners without challenge. Notably, none of the examiners in 1981 placed diagnostic emphasis on the Veteran's autobiographical book excerpts that were very detailed and articulately written. At that time, the medical examiners noted that the Veteran had many symptoms of PTSD complicated by self-medication with alcohol and drugs. From the Veteran's own statement, he engaged only briefly with hypnotherapy and proceeded to abandon substance abuse, enter into a five year and later a 16 year marriage, work as a construction employee, and run successful businesses with partners and customers. The Board acknowledges that may have had unusual ideas regarding good, evil, and religion but these were not found to be indications of delusions or hallucinations until 2011. Therefore, the Board finds that the Veteran had symptoms of PTSD prior to March 2006 but not that the impairment was either total or severe continuously since service. Second, the Board places low probative weight on the contention of the Veteran and the conclusions of the consulting psychiatrist that a poorly managed, unprofitable small business necessarily equates to unemployability. It is credible and consistent with the medical and lay assessments that the Veteran had difficulty with concentration, motivation, and in some instances, control of his practice of sharing unusual religious ideas with others. It is reasonable that these symptoms resulted in poorly bid contracts, loss of profitability, and possible alienation of customers. Although the Board acknowledges and will not disturb the award of a TDIU effective the same date as service connection in March 2006, there is no evidence prior to January 12, 2011 that the Veteran was unable to operate vehicles and machinery and employ his construction skills as an employee. Even after January 2011, the Veteran was able to live independently, manage personal funds, drive an automobile, and perform household chores. There is no evidence that he was prescribed psychotropic medications that would interfere with function as an employee in a trucking or construction occupation. The Board considered the record review and report of the consulting psychologist in 2013 but places somewhat less probative weight on his opinions. He did not interview or treat the Veteran. His report in great part is composed of numerous and selective quotations from the record. His cited statements and opinion ignores the timing of the statements and he offers no consideration of those factors and statements tending to show a lesser degree of impairment such as the times when the Veteran was operating a successful business and his intact family relationships over a long period of time. He did not address the Veteran's refusal to participate in any form of therapy after 2006. At no point during the period from March 30, 2006 to January 12, 2011 did the Veteran's psychyiatric sympt0matolotgy meet the criteria for a schedular 100 percent rating. The credible lay and medical evidence does not show that the Veteran had a total level of occupational and social impairment during this period of time. The Veteran did not display symptoms such as gross impairment of thought and communications, delusions or hallucinations, disorientation, or severe memory deficits to the extent of an inability to remember names, or other symptoms that are characteristic of a 100 percent rating during this period of time. Although the Veteran continued to hold his views on good, evil, and religion, these thoughts did not impair his daily functioning prior to January 12, 2011. Generally, the Board finds that the Veteran's family members and bookkeeper are competent to report on the symptoms that that they observed during the period because they were consistent with observations by medical examiners. The Veteran credibly reported symptoms such as nightmares, recurrent intrusive thoughts, hypervigilance, avoidance behavior, lack of anger control, lack of motivation, and poor judgment in business decisions. He reported one panic attack in the past and recurrent suicidal ideations but no attempts or plan as he had experienced in the 1980s. In fact, there is no evidence of any treatment or medical intervention for any credible suicidal actions. The Veteran was hypervigilant, kept firearms available in the home, and expressed fearfulness of others. His family expressed concern, but there is not one incident of actual confrontation or assault or other violent acts between 2006 and 2011. The Veteran preferred to live alone and remain at home but he maintained contact with his family including his wife. He reported that his marriage was failing only because he did not wish to accompany his wife to activities outside the home. His mother reported a close relationship. The Veteran and his bookkeeper reported that he was responsible and could manage his own personal funds. Although not profitable, the Veteran did perform work during 2006 through the end of 2010 indicating a capacity for employment and activity outside the home even though infrequent because of a lack of customers for his own business, not because he could not perform the duties of an employee using his skills for a successful business. All of these factors demonstrate that the Veteran did not display total occupational and social impairment during this period of time. Contrary to the opinion of the consulting psychologist, the Board accords probative weight to the evaluation of the VA psychologist in 2006 who was aware of the history in the 1980s, accepted all the Veteran's current symptoms, and determined that the Veteran had only a mild functional deficit with above average intelligence, adequate cognitive functioning, and no psychoses. The Veteran himself reported a good relationship with his wife and the ability to control his anger. He reported that he was able to work and get along with coworkers and customers even though he did not have close friends. The Board also accords probative weight to the Veteran's reports of worsening symptoms in 2008 and the evaluation of the VA psychologist in 2009 that included strained but not broken family relationships, suicidal ideations but no plan or attempts, and greater hypervigilance but no acts of violence. Moreover, the Veteran reported that he was still able to work when work was available, and the examiner noted no delusions or hallucinations. A GAF score of 46 indicated serious but not total impairment. The Board acknowledges the Veteran's statements in 2009 and his 2010 hearing testimony as well as statements by family members and the bookkeeper. They indicate a greater but not total degree of social isolation, and the Veteran continued to work when work was available. Although his family was concerned about the Veteran's firearms in the home, there is no evidence that he used threats or violence or attempted injuries to himself or others. The Board finds that there is evidence both for and against the Veteran's entitlement a 100 percent schedular rating starting on January 12, 2011, the date of VA hospitalization when several examiners noted that the Veteran's behavior was considerably influenced by delusions and assessed an inability of the Veteran to function. GAF scores of 30 and 35 are consistent with total occupational and social impairment. This is also consistent with the Veteran's report of ceasing work entirely in December 2010. On the other hand, the Veteran was able to accomplish the activities of daily living including dressing, cooking, and household chores. Although examiners noted only fair hygiene, the Veteran later reported that he had no water in his home that day. When the RO proposed that the Veteran was not competent to handle his own funds, the Veteran and his family responded with reports of adequate functioning. They reported close relationships, adequate responsibility, and the ability to operate an automobile, all because the Veteran had been provided sufficient funds - not because of treatment or improvement of symptoms. Resolving all reasonable doubt in the Veteran's favor, the Board finds that the earliest manifestations of symptoms indicative of total occupational and social impairment, and continuing thereafter, is reflected in the records of hospitalization on January 12, 2011.. The above determinations are based upon consideration of applicable provisions of VA's rating schedule. The Board also finds that at no point prior to January 12, 2011 was the Veteran's PTSD shown to be so exceptional or unusual as to render the schedular criteria for rating the disability inadequate and to warrant a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (cited in the March 2013 supplemental SOC). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id. at 115-16; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. at 116. In this case, the Board that the applicable schedular criteria are adequate to rate the disability under consideration during the period in question. The applicable rating criteria sufficiently contemplate the Veteran's particular symptoms and the imposed degree of social and occupation impairment during the period in question. Most of the Veteran's symptoms are contemplated in assigned rating, and more significantly, the practical impact of these symptoms on occupational and social functioning is contemplated in the rating criteria and has been considered. Examples are the nature of the Veteran's relationship to his family, his ability to function in the home and as a driver or craftsman at work. Essentially, the rating criteria encompass the constellation of symptoms presented in this case and afford a total rating-such as that herein awarded from January 12, 2011-when warranted by the frequency, extent and severity of symptoms. Accordingly, for the period prior to June 8, 2011, the fundamental requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) are not met. See Thun, 22 Vet. App. at 115; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board finds that the record supports the award of a 100 percent rating for PTSD from January 12, 2011, but not earlier. The Board has favorably applied the benefit-of-the doubt doctrine in reaching the decision to award the 100 percent rating from an earlier date, but finds that the preponderance of the evidence is against assignment of a rating for PTSD in excess of 70 percent prior to that date. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A rating in excess of 70 percent for PTSD, prior to January 12, 2011, is denied. A 100 percent rating for PTSD, from January 12, 2011, is granted, subject to the legal authority governing the payment of compensation. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs