Citation Nr: 1602298 Decision Date: 01/20/16 Archive Date: 01/27/16 DOCKET NO. 11-02 030 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for service-connected posttraumatic stress syndrome (PTSD), prior to October 1, 2007. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Hubers, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1966 to December 1969 and from March 1980 to February 1982. This appeal comes before the Board of Veterans' Appeals from rating decisions by the United States Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. This matter was previously before the Board in January 2015. In relevant part, the Board granted an initial evaluation of ten percent, but no more, for the Veteran's service-connected PTSD prior to October 1, 2007. The Veteran appealed that determination to the United States Court of Appeals for Veterans Claims (Court). The Veteran specifically limited his appeal to whether the Board erred in denying entitlement to any evaluation in excess of ten percent for PTSD. In September 2015, the Court issued an Order remanding the matter to the Board for readjudication consistent with a Joint Motion For Partial Remand (JMR). The JMR indicated that the Board failed to provide an adequate statement of the reasons and bases including, particularly, with respect to whether the Veteran was entitled to a retrospective evaluation of his PTSD under Chotta v. Peake, 22 Vet.App. 80 (2009). The Court's Order dismissed, as abandoned, the remaining issues including entitlement to service connection for a left hand disability. During the pendency of this appeal, the Veteran filed several new claims, see December 2014 21-526b, including a claim for an increased rating for PTSD. A June 2015 rating decision granted an increased evaluation for PTSD effective December 11, 2014. The Veteran filed a Notice of Disagreement and the RO issued a December 2015 Statement of the Case (SOC). The Veteran has not yet perfected appeal of that issue, so those claims, including particularly the claim of entitlement to an increased rating filed in December 2014, are not currently before the Board. He will have the opportunity to fully develop his claims at the RO level and obtain the full benefit of the adjudication process prior to any consideration of those issues by the Board, if necessary. The record contains evidence not considered by the AOJ, however, the Board finds that the evidence newly associated with the claims file is not pertinent to the claim under consideration. 38 C.F.R. § 20.1304(c). The new medical records post-date the period under consideration and, to the extent they recount or refer to the Veteran's reports of symptoms during that period, they are cumulative of his prior reports. Likewise, the April 2015 VA examination for the purpose of evaluating his PTSD does not address the period under consideration and, to the extent it refers to the period prior to October 2007, the report explicitly references the October 2007 VA examination and documentation of symptoms therein. Because the evidence not yet considered by the AOJ is not pertinent, the Board may proceed to the merits without further remand. 38 C.F.R. § 20.1304(c). FINDING OF FACT Prior to October 1, 2007, the Veteran's PTSD caused occupational and social impairment due to mild or transient symptoms with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. CONCLUSION OF LAW The criteria for an initial rating in excess of 10 percent disabling for the Veteran's PTSD have not been met, prior to October 1, 2007. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.130 Diagnostic Code (DC) 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Under 38 U.S.C.A. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). In deciding the Veteran's claim, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event; or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). I. Entitlement to an Initial Compensable Rating: PTSD Initially, the Veteran contended that he was entitled to a 10 percent rating for the period November 27, 2002, through October 1, 2007. See, e.g., January 2010 Notice of Disagreement ("the ten (10) percent award should have been granted effective November 27, 2002"). That was granted in the prior Board decision, and he appealed. A brief discussion of the legal determinations that, eventually, brought this case before the Board is warranted. Most significantly, the RO determined in a December 2009 rating decision that the Veteran was entitled to an effective date of November 27, 2002, for service connection for PTSD. Ordinarily, the effective date for the award of service connection for PTSD will be no earlier than the date of diagnosis. However, where the qualified mental health professional who diagnoses the condition is able "to identify an earlier onset date based on preexisting symptoms", the effective date may predate the date of diagnosis. See, e.g., Young v. McDonald, 766 F.3d 1348, 1352 (Fed. Cir. 2014). Here, the VA examiner (a psychiatrist) who diagnosed the Veteran specifically opined that the Veteran had experienced "mild" symptoms "since 1969", those symptoms had never been in remission, the symptoms were chronic, and the Veteran had "quietly harbored symptoms" of PTSD "since discharge." See October 2007 VA Examination. This evidence supports the RO's determination that an effective date of the date of claim was appropriate and also suggests that, during the relevant period, the Veteran had persistent symptoms that warrant, at minimum, a ten percent rating. The Board will carefully examine the evidence in light of the legal standards to determine whether any higher evaluation is warranted. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In the appeal of an initial assignment of a disability rating, evidence to be considered is not limited to that reflecting the current severity of the disorder. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In cases where an initially assigned disability evaluation has been disagreed with, it is possible for a Veteran to be awarded separate evaluations for separate periods based on the facts found during the appeal period. Id. at 126; see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). PTSD is evaluated under the General Rating Formula for Mental Disorders found in 38 C.F.R. § 4.130. See 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (2013). Under the General Rating Formula, a noncompensable rating is warranted where a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent evaluation is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent evaluation is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 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 effective work and social relationships. A 70 percent evaluation is warranted where the disorder is manifested by 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 disability evaluation is warranted where there is 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. Id. The nomenclature employed in the rating schedule is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as the "DSM-IV"). 38 C.F.R. § 4.130 (2013). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between 0 and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The DSM-IV contemplates that the GAF scale will be used to gauge a person's level of functioning at the time of the evaluation (i.e., the current period) which will generally reflect the need for treatment or care. While GAF scores are probative of the Veteran's level of impairment, they are not to be viewed outside the context of the entire record. Therefore, they will not be relied upon as the sole basis for an increased disability evaluation. A GAF score of 51-60 indicates 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 peer or coworkers). A score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A score of 71-80 indicates that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational or school functioning (e.g., temporarily falling behind in schoolwork). When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In determining the actual degree of disability, contemporaneous medical records and an objective examination by a mental health professional are more probative of the degree of the Veteran's impairment than his assertions that a particular rating should be assigned. This is particularly so where the rating criteria require analysis of the clinically significant symptoms of a complex mental health condition, but the Veteran is a layman. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012). The Board finds that the medical opinions of this Veteran, who lacks mental health training, are not competent evidence of the clinical significance of his symptoms. Id. Likewise, the Board is not competent to any medical determination regarding his subjectively reported symptoms. See Colvin v. Derwinski, 1 Vet.App. 171, 175 (1991). The Board, however, has considered the Veteran's subjective reports of symptoms, particularly as they illuminate or underscore the medical opinions of record. See Chotta, 22 Vet.App. at 84. As the Veteran frankly acknowledges and the evidence of record establishes, he did not seek treatment and was not evaluated for PTSD prior to his October 2007 VA examination. See, e.g., April 2012 VA Form 9; October 2007 VA Examination Report. However, as noted above, the VA examiner specifically determined that the Veteran had been experiencing mild, chronic symptoms for many years prior to the original diagnosis. With respect to symptoms prior to October 2007, the VA examiner stated that the Veteran's symptoms "have been gradually increasing over the last five years." The examiner noted that the Veteran was able to participate in meaningful interpersonal relationships with family and friends and was able to maintain employment, but that the Veteran's "primary coping strategy [was] to immerse himself into constant work and high risk activities as a means of distraction from memories of the war." The examiner noted that the Veteran did not have suicidal or homicidal ideation, communication problems (e.g. abnormal speech or thought), hallucinations, impaired thought processes or perceptions, or impaired judgment. The examiner did note some impairment of recent and short-term memory, but also an intact remote memory. The examiner opined that the Veteran had limited insight and a restricted affect. The Veteran described his mood as tense, anxious, and impatient. Overall, the examiner concluded that the Veteran had only mild impairment in industrial and social functioning. He assigned a GAF of 70. These symptoms warranted the assignment of a 10 percent rating, but no more. The symptoms had only a mild impact on social and occupational functioning and, other than the Veteran's self-report of anxiety and the evidence of some mild memory impairment, he did not display the type or severity of symptoms that warrant any higher rating. The Veteran has contended, in part, that the VA should have scheduled an earlier examination and, if it had, the examination would have documented his PTSD and associated symptoms at an earlier date. The Board recognizes the perception of unfairness in the five year delay in obtaining a VA examination, but to the extent he is raising an argument couched in equity, the Board is bound by the law and is without authority to grant benefits on an equitable basis. See 38 U.S.C.A. §§ 503, 7104(c) (West 2014); see also Harvey v. Brown, 6 Vet. App. 416, 425 (1994). The Board cannot speculatively conclude he would have received a higher rating had an examination been done. The Board has evaluated all of the evidence to the end that its decisions are "equitable and just as contemplated by the requirements of the law." 38 C.F.R. § 4.6. Although the medical evidence suggested worsening symptoms over the five years prior to October 2007, there was no clear indication of the degree of worsening. The evidence establishes, though, that the Veteran was coping by immersing himself in work and engaging in high risk activities. These manifestations appear from the record to have been present throughout the appeal period and, so, warrant an initial 10 percent rating as the Board previously concluded. In making this finding, the Board notes that the Veteran is entitled to the benefit of any doubt. 38 C.F.R. § 4.3. Moreover, the higher of two ratings should be assigned where "there is a question" as to which rating is should be assigned and "the disability picture more nearly approximates the criteria required for that rating." 38 C.F.R. § 4.7. All doubt was resolved in the Veteran's favor when the Board assigned him a 10 percent rating, because that is based on his lay statements of symptoms he experienced, since there is no medical evidence whatsoever to review from that period. The Board previously concluded his complaints more closely approximated mild or transient symptoms which decreased work efficiency only during periods of significant stress. As already discussed, no higher rating is warranted. Even according the Veteran's statements full weight, there is no evidence supporting a finding that he experienced more than mild or transient symptoms impairment in social and occupational functioning during the period on appeal. The greater weight of the evidence is against the claim of entitlement to an initial rating in excess of 10 percent for PTSD. The benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. at 53-56. The Veteran's claim for an evaluation in excess of 10 percent for PTSD prior to October 1, 2007, is denied. II. Extraschedular Rating The Board has considered whether an extraschedular evaluation is warranted for the Veteran's PTSD during the period under consideration. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111, 118-19 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairments caused by the Veteran's service-connected PTSD are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The greater weight of the evidence establishes that the Veteran's disability picture during the period under consideration is adequately contemplated by the applicable schedular rating criteria, which have been discussed above with respect to the issue on appeal. The Veteran has not expressly raised the matter of entitlement to an extraschedular rating. In any case, the Board has considered whether the criteria for higher schedular ratings were met, but, as discussed in the merits section above, the Veteran's symptoms most closely approximate, and are adequately described by, the rating criteria for a 10 percent schedular rating. The Board finds no evidence that his occupational and social impairments were greater than those with PTSD symptoms of the same or similar type and severity. Interference with employment is not a factor in the first step of the Thun analysis and, so will not be further discussed. The Board also finds that the rating schedule is adequate, even in regard to the collective and combined effect of all of the Veteran's service connected disabilities (PTSD and knee), and that referral for extraschedular consideration is not warranted under the circumstances of this case. Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014). The evidence is against finding that the combination of his service-connected disabilities produces a disability level or symptomatology that is not reasonably described by the schedular rating criteria. On the record now before the Board, referral for an extraschedular rating for PTSD during the period under consideration is not warranted. III. Duties to Notify and to Assist When VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided relevant notice to the Veteran on multiple occasions, including in July 2005 and October 2007 prior to the initial adjudication of his claim. There were no findings from the Court that notice - or the Board's discussion thereof - was in any way deficient. VA's duty to assist includes assisting the claimant in the procurement of service and other relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO associated with the claims file the Veteran's available service treatment records, VA treatment records, and various lay statements. As previously discussed, VA was able to locate and obtain only some records (and no service treatment records) from the Veteran's first period of active service (November 1966 to December 1969). See January 2010 Formal Finding of Unavailability of Service Treatment Records. The Veteran was so notified by letter in January 2010. In any event, since service connection for PTSD has been granted, service records are not relevant to the question of the rating to be assigned. VA attempted to obtain records from the Social Security Administration and, in March 2011, made a Formal Finding of Unavailability of Social Security Records. However, the Veteran responded in a March 2011 statement that he had never applied for Social Security benefits and was, in fact, "still employed as of today." The Veteran has not identified any other records allegedly relevant to his claim. VA has satisfied its duty to obtain records. The Veteran underwent an October 2007 VA examination pertinent to the claim on appeal. The examiner reviewed the Veteran's pertinent medical history, conducted a clinical evaluation of the Veteran, and provided an adequate discussion of relevant symptomatology. The examiner opined on the etiology of the condition and its history. The PTSD examiner also provided an opinion directly addressing the functional impacts of the Veteran's PTSD symptoms including the impact on his occupational functioning. The examination and opinions are adequate. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). The Court has directed the Board to provide an adequate statement of reasons or bases with regard to whether VA was required to provide the Veteran with a retrospective medical opinion. See September 2015 JMR at p. 4; Chotta, 22 Vet.App. at 85. As discussed above and in the Board's January 2015 decision, the record already contains a retrospective opinion in the October 2007 VA examiner's report. The October 2007 VA examiner examined the pertinent medical records and evidence relating to the period now under consideration. As part of the examination, the Veteran was questioned regarding his psychiatric, family, and employment history. The examiner recorded and considered the Veteran's subjective reports of symptoms and functional impacts during the period under consideration. The examiner explicitly found that the Veteran's symptoms had been "mild...since 1969." As noted above, the examiner opined that the Veteran's symptoms had been "gradually increasing over the last five years", i.e. from 2002 to 2007, but remained mild as reflected in the assigned GAF of 70 and the examiner's narrative explanation. The VA examiner's findings that the symptoms were "mild" in October 2007 (including GAF of 70) and had been "gradually increasing" since 2002 necessarily entails the medical determination by the VA examiner that the symptoms prior to October 2007 were no more than "mild" and would not have warranted a GAF in excess of 70. The only ambiguity in the record was whether the Veteran's "mild" symptoms prior to October 2007 were sufficiently significant to warrant any compensable rating. The Board resolved that doubt in the Veteran's favor when the 10 percent rating was granted. Beyond that question, the record contains an explicit, retrospective opinion that the severity of the Veteran's PTSD symptoms prior to October 2007 were no more than mild. The available evidence, including an adequate, retrospective opinion by the October 2007 VA examiner, is sufficient to rate the Veteran's claim. Chotta, 22 Vet.App. at 84-85. The Board finds that the October 2007 VA examination was adequate and, in addition, that VA had no duty to provide additional examinations, to include obtaining any additional retrospective opinions, with respect to the Veteran's PTSD. In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to his claims currently on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103 and 5103A; 38 C.F.R. § 3.159. ORDER Entitlement to an initial evaluation in excess of 10 percent for service-connected posttraumatic stress syndrome (PTSD), prior to October 1, 2007, is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs