Citation Nr: 1605475 Decision Date: 02/11/16 Archive Date: 02/18/16 DOCKET NO. 04-29 271 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for tonsillar squamous cell carcinoma with metastasis, to include residuals claimed as scarring, muscle damage, and nerve damage. 2. Entitlement to a rating in excess of 30 percent prior to May 25, 2005, in excess of 50 percent from May 25, 2005, and in excess of 70 percent from April 12, 2013, for posttraumatic stress disorder (PTSD). 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU rating), effective prior to February 25, 2010. REPRESENTATION Appellant represented by: Kenneth C. Carpenter, Attorney at Law ATTORNEY FOR THE BOARD D.M. Casula, Counsel INTRODUCTION The Veteran had active service from September 1966 to August 1968, and from August 1974 to August 1977. This matter comes before the Board of Veterans' Appeals (Board) from a March 2005 rating decision of the San Juan, Puerto Rico Regional Office (RO) of the Department of Veteran Affairs (VA), which denied service connection for tonsillar squamous cell carcinoma with metastasis, left neck dissection, pharyngeal carcinoma. This matter further comes before the Board from a January 2011 RO rating decision which granted service connection for PTSD and assigned a 30 percent rating effective from June 24, 2002, and a 50 percent rating, effective from May 25, 2005. By December 2013 rating decision, the RO granted a 70 percent rating for PTSD, effective from April 12, 2013. In June 2008, the Board remanded the issue of entitlement to service connection for tonsillar squamous cell carcinoma with metastasis for further development. Review of the record shows that there was substantial compliance with the June 2008 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The record reflects that in November 2013, the Veteran moved to Indiana. Thereafter, jurisdiction of this matter was transferred to the Indianapolis RO. In October 2015, the Veteran testified at a videoconference hearing, at the RO, before the undersigned Veterans Law Judge, with respect to the service connection claim only. By December 2010 rating decision, the RO granted service connection for ischemic heart disease, associated with herbicide exposure, and assigned a 10 percent rating, effective from December 22, 2008, and a 100 percent rating, effective from February 25, 2010. With regard to the claim for a TDIU rating, the grant of a schedular 100 percent disability rating moots the issue of entitlement to a TDIU rating, after the effective date of that rating. Herlehy v. Principi, 15 Vet. App. 33 (2001). Thus, in the current appeal, the claim for a TDIU rating is essentially moot since the May 25, 2005 effective date of the 100 percent rating for ischemic heart disease. Thus, the TDIU issue before the Board is as set forth above. FINDINGS OF FACT 1. The Veteran had active military service in the Republic of Vietnam during the Vietnam era and is presumed to have been exposed to Agent Orange and/or other herbicide agents. 2. With consideration of the doctrine of reasonable doubt, there is competent and probative medical evidence of record suggesting that the Veteran's tonsillar squamous cell carcinoma with metastasis, to include residuals claimed as scarring, muscle damage, and nerve damage, is related to his exposure to Agent Orange during active military service. 3. For the period from June 24, 2002 forward, the Veteran's PTSD was manifested by no more than occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking or mood, due to multiple symptoms both listed in the rating criteria, and not listed in the rating criteria; at no time does the competent evidence of record show that the symptoms due to the Veteran's PTSD was productive of total social impairment or were of such frequency, severity or duration to equate to total social impairment. 4. Resolving reasonable doubt in favor of the Veteran, prior to February 25, 2010, the Veteran was precluded, by reason of his service-connected PTSD, from obtaining and maintaining any form of gainful employment. CONCLUSIONS OF LAW 1. Giving the benefit of the doubt to the Veteran, tonsillar squamous cell carcinoma with metastasis, to include residuals claimed as scarring, muscle damage, and nerve damage, were incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2015). 2. For the period prior to April 12, 2013, the criteria for a 70 percent rating for PTSD, but no higher, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, DC 9411 (2015). 3. From April 12, 2013, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, DC 9411 (2015). 4. Prior to February 25, 2010, the criteria for a TDIU rating have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2015). For the issues decided in the instant document, VA provided adequate notice in a letter sent to the Veteran in July 2002. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claims. VA has obtained all identified and available service and post-service treatment records for the Veteran. Further, the Veteran underwent VA examinations in October 2002, May 2005, November 2008, June 2011, and July 2014, each of which is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). It appears that all obtainable evidence identified by the Veteran relative to his claim has been obtained and neither he nor his representative has identified any other pertinent evidence which would need to be obtained for a fair disposition of this appeal. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board concludes that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claims under the VCAA. No useful purpose would be served in remanding this matter for yet more development. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Service Connection Claim Service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). The existence of a current disability is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). With regard to the Veteran's claim for service connection for a condition alleged to be due to herbicide agent exposure (e.g., Agent Orange), the Board notes that a veteran who served in the Republic of Vietnam between January 1962 and May 1975 shall be presumed to have been exposed during such service to a herbicide agent, absent evidence to the contrary. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6). In this case, the Veteran did serve in the Republic of Vietnam during the pertinent period; thus he is presumed to have been exposed to herbicide agents. Under 38 C.F.R. § 3.309, certain enumerated diseases, to include ischemic heart disease and diabetes, associated with exposure to certain herbicide agents will be service connected if a veteran is found to have been exposed to such an agent. The Secretary of VA reiterated that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined that a presumption of service connection is warranted. See, e.g., 72 Fed. Reg. 32,395 (Jun. 12, 2007). If there is no presumptive service connection available, direct service connection can be established if the record contains competent medical evidence of a current disease process that has been related to exposure to an herbicide agent while in service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303 Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Lay persons are competent to provide opinions on some medical issues, however, some medical issues fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); see also Jandreau v. Nicholson, supra. The Veteran contends that his tonsillar squamous cell carcinoma with metastasis was caused by exposure to Agent Orange during his active service in Vietnam. Regarding existence of current disability, review of the record reveals private and VA treatment records showing that the Veteran has residuals of tonsillar squamous cell carcinoma. With regard to a relationship between the Veteran's tonsillar squamous cell carcinoma with metastasis, to include residuals, the Board notes there are both VA and private medical opinions regarding such a relationship. First, in support of the Veteran's claim are several medical opinions. In a letter dated in November 2004, Dr. Berke indicated he performed a direct laryngoscopy, esophagoscopy, tracheostomy, midline mandibulotomy, left modified radical neck dissection, and a wide local excision of left pharyngeal tonsillar carcinoma, on the Veteran. Dr. Berke opined that the Veteran's left tonsillar squamous cell carcinoma with neck metastases could be a direct result of exposure to Agent Orange while in service in Vietnam. In a letter dated in December 2004, Dr. Treadwell opined that the Veteran's cancer could be as a result of direct exposure to Agent Orange, noting that there has been some data that suggests Agent Orange can contribute to squamous cell carcinoma of the upper aerodigestive tract, but that the Veteran also had a risk from smoking. Dr. Treadwell opined that it was more likely than not that either the Veteran's exposure to Agent Orange or his smoking history contributed to his malignancy. In letters dated in January 2007 and February 2008, Dr. Bash opined that it was at least as likely as not that the Veteran's tonsillar squamous cell carcinoma with metastasis, left neck dissection, pharyngeal carcinoma was caused by Agent Orange exposure. Further, on the VA examination in July 2014, the examiner indicated that there were three potential factors that could be related to the Veteran's history of head and neck cancer, but opined that it was impossible to determine which of these was the causal agent. The examiner found it reasonable that Agent Orange exposure was a risk factor for head and neck squamous cell carcinoma, and opined that it was as likely as not that Agent Orange may have played a role in the Veteran's cancer. In August 2014, the same VA examiner was asked to provide clarification of his previous comments, and indicated that the Veteran had multiple risk factors that were known to contribute to the development of head and neck cancer, including smoking and Agent Orange exposure, but because there was no test that could confirm the cause of a particular person's cancer, any statement about causation would be speculative. The examiner noted review of the other physicians' opinions, and opined that since Agent Orange was a known carcinogen, it was possible that the Veteran's cancer was caused by this exposure. The examiner concluded that it was as likely as not that the Veteran's cancer was due at least in part to Agent Orange exposure. The Board also notes that there were two other medical opinions provided, by VA examiners, including the December 2008 VA examination report in which the examiner reported he had not seen enough cases of cancer of the tonsil due to exposure to Agent Orange, but that it was an important fact that the Veteran was a heavy smoker, which was a well-documented cause of squamous cell carcinoma of the upper respiratory sac. The examiner opined that it would be speculative to state that the Veteran's cancer was due to Agent Orange. Further, in October 2014, the same VA examiner who provided opinions in July and August 2014, was again asked for clarification, and the VA examiner opined that any conclusion that was drawn about the cause of an individual's head and neck cancer was speculative and, therefore, he was not able to provide more definitive answer to the question. The Board notes that such conclusions (in December 2008 and October 2014) essentially amount to non-opinions and are basically of no probative value here. See Fagan v. Shinseki, 573 F. 3d 1282 (Fed Cir. 2009) (holding held that when an examiner is unable to come to an opinion such "non-opinion" is neither positive nor negative support for a claim of service connection and is, therefore, not probative evidence). As set forth above, the Board notes that there are competent medical opinions which support a link between the Veteran's tonsillar squamous cell carcinoma with metastasis and exposure to Agent Orange during active service, and provide a rationale for this opinion. There are also some non-opinions of record, by VA examiners, which have no relevance. Thus, the competent medical evidence is in relative equipoise as to whether his tonsillar squamous cell carcinoma with metastasis, to include residuals, is related to active service. Accordingly, in resolving reasonable doubt in the Veteran's favor, service connection for tonsillar squamous cell carcinoma with metastasis, to include residuals claimed as scarring, muscle damage, and nerve damage, is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, III. Higher Ratings for PTSD The record reflects that the Veteran's PTSD has been assigned a 30 percent rating, effective from June 24, 2002; a 50 percent rating, effective from May 25, 2005; and a 70 percent rating, effective from April 12, 2013. The Veteran essentially contends he should be entitled to a 70 percent rating for PTSD, effective from June 2002, and a 100 percent rating, effective from the date he stopped working in January 2003. Disability evaluations are determined by application of the VA Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has been established and a higher initial disability rating is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of the veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD has been rated under DC 9411, which provides that a 30 percent rating is assigned 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, DC 9411. A 50 percent rating is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereo-typed 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, and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for PTSD when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, 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); and the inability to establish and maintain effective relationships. Id. A 100 percent rating for PTSD requires 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; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 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. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Analysis should not be limited to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436 (2002). GAF scores and the interpretations of the score are important considerations in rating a psychiatric disability, however, the GAF score assigned is not dispositive; rather, such score(s) 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); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). Background and Analysis On a VA examination in October 2002, the Veteran reported recurring dreams about Vietnam, as well as sleeplessness and night sweats. He avoided war movies, and conversations, feelings, and thoughts regarding war trauma. It was noted that his symptoms did not affect functioning and he denied feeling sad, hopeless, or helpless. He worked full time for the Federal Bureau of Prisons. He was divorced, lived alone, and trying to be in a relationship. He worked during the daytime, and also watched television and worked out. He went fishing and golfing for recreation. On mental status examination, he was cooperative, made good eye contact, and had a euthymic mood. His speech and thought processes were normal, and he denied hallucinations and suicidal or homicidal ideation. He had good insight, judgment, memory, and concentration. There was no psychiatric diagnosis and the Axis I diagnosis was alcohol abuse. The examiner noted that PTSD and depression were not seen during this visit and that the Veteran was functioning very well. A GAF score of 60 to 65 was noted. A November 2003 psychiatric initial evaluation showed that the Veteran reported he wanted to "end it all". He was admitted due to depressive symptoms and self-harm ideation. He reported several weeks of feeling depressed, but that his symptoms had been aggravated in the past two weeks. He reported feeling sad, depressed, loss of interest in activities, crying spells, trouble sleeping, poor memory and concentration, feelings of worthlessness and hopelessness, and isolation. He reported self-harm ideation by hanging because he did not have a gun, and reported prior suicidal attempts many years ago due to depressive symptoms. He reported no harm to others ideation or attempt. He reported hearing male voices call him by name, but denied hearing or seeing things that are not noted by others. He denied inflated self-esteem, grandiosity ideation, decreased need for sleep, being more talkative than usual, racing thoughts, or distractibility. He reported he had been drinking 12 to 15 beers a day until passing out, and reported blackout periods, morning shakes, and legal and marital problems due to alcohol. He had not been on a detox program despite drinking the past 32 years. On mental status examination he was oriented, had fair hygiene, and appeared downcast but was cooperative. He had mild to moderate psychomotor retardation, and was calm but with hand tremors. His speech was non-spontaneous and with decreased volume. His mood was depressed and affect restricted. His thought process was coherent, logic, and relevant, and he had no suicidal or homicidal ideation and no ideas of reference or delusions. There were no auditory or visual hallucinations present. His memory, concentration, attention, and insight were fair, and judgment was poor. The assessment was he had a history of a depressive disorder and alcohol dependence who was admitted with depressive symptoms and self-harm ideation, and expressed feeling better but continued with marked depressive symptomatology and intermittent death wishes, but was able to contract for safety. He had mild alcohol withdrawal symptomatology (tremors) and was to start on antidepressive medication and optimize pharmacotherapy for alcohol withdrawal prevent. His diagnoses included alcohol-induced mood disorder with depressive features. VA treatment records showed that in December 2004, the Veteran was seen in the mental health clinic. He reported that the medicine was helping him and he slept a bit more and was not as restless as before. It was noted that the Veteran was married (for 5 months, but had been living together over 25 years), and was retired for 2 years, after working 30 years of federal employment. It was noted that he had depressive and anxiety/panic episodes and PTSD symptoms during the later years of his government service, and had been receiving treatment for this for about a year. He took an antidepressant with a good response. He was seen for episodes of depression, anxiety/panic, restless sleep, frequent dreams/nightmares, mood instability, getting easily upset, and temper dyscontrol. His medications were reviewed, and he was to continue his current dose with the possibility of being placed on a mood stabilizer when the need comes. On mental status examination, the Veteran presented with a blunted and constricted affect which was congruent to his dysphoric mood, and he reported continuing symptomatology as noted above, but less than before. He reported he was able to get about 5-6 hours of sleep and took some naps during the day, and reported it was easier to fall back to sleep. He denied delusions or hallucinations, and admitted to some depression but no other acute mental status findings, and he denied homicidal or suicidal ideation. The examiner noted the Veteran had a panic disorder with agoraphobia, depression, and symptomatology of bipolar disorder and PTSD, which was responding to Sertraline. His GAF score was 53. VA treatment records showed that in February 2005 the Veteran reported he was "doing alright, but not too well" and his panic attacks had slowed down. He stayed away from people to reduce panic and anxiety, but he was more depressed now. His irritability and temper outbursts were thought to be related to a number of issues including, anxiety/panic, bipolar versus depression, situational, as well as related to a history of heavy alcohol abuse in the past and PTSD features. On mental status examination, the Veteran was noted to have a restricted to appropriate affect, congruent to his depressed mood. His speech was spontaneous and relevant. He reported having depression, anxiety and irritability, saying it does not take much for him to really go off. He denied delusions, hallucinations, and violent or suicidal ideations. The assessment was he continued to manifest symptoms of panic disorder with agoraphobia and depression, as well as bipolar, adjustment disorder, and anxious mood associated with a recent serious medical/surgical problem, and probable PTSD. A GAF score of 51 was assigned. Further, VA treatment records showed that in February 2005, his chief complaints included symptoms of chronic combat trauma PTSD including re-experiencing memories and nightmares triggered by familiar sights and smells like Vietnam, avoidance of people, activities outside the home, and feelings and problems with sleep, anger, and hypervigilance. He reported being treated for alcohol dependence and was diagnosed with PTSD at a VA facility in Puerto Rico. He reported that his mother and sister lived in Ohio but he had rare phone contact with them. He reported he had been married twice, and was separated from his current wife who he married last year. He had an adult son who he got along with, and reported he lived in his son's house and would likely to continue to do so, at least near future. He reported he stopped working for medical reasons a few years prior. On mental status examination, the Veteran was found to be oriented, agitated, with pressured/pushed speech, a labile affect, and an angry, anxious, and depressed mood. He denied hallucinations and his thought process was normal. With regard to suicidal or violent ideation, it was noted that he had a history of suicidal ideation with plan and means, but not current intent. His insight was limited, he was found to be impulsive, and his memory was intact. In assessing the Veteran's danger to himself, it was noted that he was a moderate risk because of a recent cancer surgery to neck, and his history of suicidal ideation with a plan to hang himself. He was assessed to have a low risk of danger to others at that time, but also noted to have moderate risk due to history of violence and chronic anger. The diagnoses included panic disorder with agoraphobia, depression, and PTSD features; adjustment disorder with mixed emotion, conduct, and associated life threatening medical/surgical problem; and PTSD versus bipolar disorder, NOS; and a GAF score of 35 was assigned. His primary problems were listed as depression, anxiety, irritability, mood instability, temper outburst, and problems sleeping with bad dreams and nightmares. His behaviors included episodes of panic attacks and anxiety, recurrent and intrusive distressing recollections of the severe traumatic events; intense distress when exposed to reminders of the traumatic events; avoidance of thoughts, feelings or conversations about the traumatic events; a pessimistic and fatalistic attitude regarding the future; and temper outbursts. On the VA examination in May 2005, the Veteran reported that in the last year he had felt anxiety, restlessness, tension, irritability, and insomnia, with an inability to concentrate. He reported working as a correctional officer until he retired in February 2003, after 25 years of service. It was noted that he was a divorced father of two children and at present living with his girlfriend. On mental status examination it was noted that he was inappropriately dressed with poor hygiene, was not shaving, and was cooperative but manipulative. He was not spontaneous and established poor eye contact with the examiner, but was alert, oriented, and in contact with reality. There was no evidence of psychomotor retardation or agitation, any tics, tremors, or abnormal involuntary movement. His thought process was coherent and logical, and there was no looseness of association and no disorganized speech, and no evidence of delusions or hallucinations. He reported no phobias, obsessions, panic attacks, or suicidal ideas. His mood was anxious, and his affect was broad and appropriate. His memory was intact, his judgement was fair, and insight was poor. It was noted that he had a strong denial and rationalization of his alcohol dependence problem. The examiner noted that the signs and symptoms described above were seriously interfering with the Veteran's employment functioning and seriously interfering with his social functioning. It was also noted that the Veteran was able to maintain basic activities of daily living. The examiner concluded that the Veteran's mental disorder did not meet the DSM-IV criteria to establish a diagnosis of PTSD, noting that the Veteran was not able to specify and describe in detail a severe and horribly traumatic event or incident experienced in combat. The examiner noted the Veteran was not observed to become anxious, distressed, or depressed when he was expressing his experiences in Vietnam, and that there was no evidence in his clinical picture of avoidance of a stimuli associated with a trauma. Finally, it was noted that the Veteran's memories about Vietnam were not intrusive, persistent, and distressing thoughts interfering with daily function. The diagnoses included alcohol dependence and anxiety disorder. A GAF score of 50 was assigned, and it was noted the Veteran had serious symptoms and serious impairment in his social and occupational functioning. The Veteran was hospitalized from September 2005 through December 2005 for a PTSD Residential Rehabilitation Program (PRRP). On admission, his diagnoses included chronic PTSD and alcohol dependence in remission, and a GAF score of 45 was assigned. On discharge, his diagnoses included chronic PTSD, alcohol dependence in full sustained remission, and early dementia. A GAF score of 48 was assigned. In a VA psychiatry general note dated in October 2005, on mental status examination, the Veteran appeared alert and oriented, with fair hygiene and grooming. He was calm and cooperative, had proper eye contact, speech was clear and coherent, and his mood was fine but affect was mildly anxious. His thought process was organized and goal directed, and thought content showed no evidence of psychosis. He was not suicidal or homicidal, had fair insight and judgment, acceptable attention and concentration, and his memory was at documented baseline. He had been feeling well but still had nightmares and poor sleep, and discussed how he had been able to relate with other residents whose location in Vietnam was close to his. The results of a neuropsychological examination suggested mild impairment of his mental abilities due to compromised brain functioning, and his performance pattern suggested bilateral cerebral dysfunction, but the etiology of this was unclear. It was noted that he was pleasant and cooperative, but had difficulties listening to input due to anxiety and fidgeting and he had to be redirected, after which he was able to answer questions adequately and was concrete in his responses. The Veteran was hospitalized from March 2007 through June 2007 for treatment in the PRRP. He described symptoms of flashbacks, intrusive thoughts, anxiety, panic attacks, explosive rage, irritability, difficulty concentrating, and poor memory. He also described survivor guilt. On physical examination, his general appearance was described as good. He successfully graduated from PRRP and his condition was improved on discharge. His estimated GAF at discharge was 50. In a June 2007 VA treatment record, it was noted that the Veteran had just returned from a 3 month PRRP program, and that his intrusive thoughts, hyperalertness, and isolation symptoms had improved with the help of medication and the 3 month inpatient program. On mental status examination he was found to be well dressed and groomed, was alert and oriented, and had an appropriate flow of words. He was not experiencing suicidal or homicidal ideation, or hallucinations or delusions. He had a dysthymic/anxious mood and affect, and was sleeping 2 to 3 hours a night with frequent awakenings. He experienced episodes of exacerbated depression. A GAF score of 50 was assigned. In a Vet Center summary of treatment dated in July 2007, it was noted that the Veteran had been a client since October 2003 and had participated in group and individual therapy sessions for management of PTSD symptoms. It was noted that although the Veteran had been able to work for the Federal Bureau of Prisons, he continued to experience anxiety episodes, intrusive thoughts, insomnia, and problems with anger, and that he retired in January 2003 and relocated to Puerto Rico with his wife. It was also noted that over the years, he continued to re-experience traumatic events by way of intrusive thoughts, nightmares and feeling very distressed when exposed to stimuli including war movies, loud noises, people screaming, etc. He tried to avoid talking about his war experiences, felt detached emotionally from others, and showed a limited range of emotions. He experienced insomnia, startled easily, felt hypervigilant, and had difficulty managing anger. He had panic attacks 4 to 5 times a week, and was agoraphobic when in close spaces. The therapist opined that the Veteran's neuropsychiatric condition continued to significantly affect his cognitive and social skills, and significantly impaired his ability to maintain effective social relationships. The diagnosis was PTSD, chronic, prolonged. In a December 2007 VA psychiatry note, the Veteran reported poor sleep but no suicidal ideation. He was alert and oriented, his mood was anxious, his thought process and speech were normal, and a GAF score of 70 was assigned. In January 2008, the Veteran was seen for individual psychotherapy to have a medication filled. On examination his mood was irritable and his affect was restricted to mood and labile at times. He was easily provoked to anger. It was noted that he was angry and hostile, and made negative comments the entire session, even when not pertinent about the government. His speech was within normal limits and thought process was tangential in making negative comments about the government and needing to be redirected to answer questions. There was no evidence of delusions, he denied hallucinations, and his judgment and insight were limited. There was no evidence of psychomotor agitation, and he denied suicidal and homicidal ideation, intent, or plan. VA treatment records show that in February 2008, the Veteran was seen for a psychiatry initial evaluation and he reported he had had a bad dream and almost hit his wife. He continued to have nightmares and flashbacks of the Vietnam War, but his symptoms had decreased since the PTSD program he attended. He tried to avoid these thoughts of the Vietnam war, and stayed mostly isolated. He was hypervigilant and startled a lot, and his mood was usually irritable and angry. He reported decreased interests and low energy, and felt hopeless and frequently had suicidal ideation, but denied suicidal ideation at that time. He reported that a couple of months prior he planned to hang himself, but indicated he had "not got that low yet". He denied homicidal ideation, but reported that when he got into confrontations he sometimes wanted to kill the other person by choking and one time had dragged a person when he was angry. He reported that he attended anger management sessions and that had helped him to learn how to avoid confrontations. He reported having racing thoughts and that he was an anxious person and worried about things that "you don't worry about". He sometimes heard his friends talking to him and answered back. He denied command hallucinations, but reported that the voices made him feel guilty. He reported that during a flashback he had visual hallucinations. He reported he retired from the Justice Department after working there for 25 years. For leisure activities he played with his dogs. On mental status examination his hygiene was good. He was cooperative and maintained fair eye contact. His speech was regular in rate, but explosive at times. His attention, concentration, and memory were intact, and judgment and insight were fair. His mood was irritable and affect was reactive. The diagnoses included chronic PTSD and mood disorder, and a GAF of 60 was assigned. A report from Fairfield Medical Center showed that in October 2008, the Veteran was visiting family in Ohio in order to see his cardiologist, but was brought to the hospital because of concern about psychotic symptoms. He reported that the day prior he was definitely saying things. He reported he was supposed to have an MRI of his back, and also stated he came in with "electroschocks behind his back" which reminded him of some things he had experienced in Vietnam. On examination, he seemed to be alert and oriented, but then periodically would appear to be psychotic responding to something, which may have been a reflection of his PTSD, and then indicating he was supposed to have an MRI of his back, which, according to the nursing staff, was not accurate information. It was noted that he was willing to sign himself in voluntarily to the psychiatric unit if deemed appropriate for him. It was also noted that he was pleasant initially, and then he appeared to be anxious and depressed, and seemed to be responding to hallucinations, but the examiner noted that this could have been a reflection of PTSD in terms of having a flashback. When describing the electroshock down his back, it appeared that the Veteran was then going into Vietnam and he admitted to having visual hallucinations the day before. It was also noted that the Veteran seemed fixed on having an MRI of his back when in fact that has never been discussed or ordered for him. The assessment was that the Veteran seemed to have come in with psychosis and PTSD as part of the medical issue. A psychiatric admission was to be considered if the Veteran was found to be medically stable. The diagnoses included PTSD and depression, and the Axis V GAF score was listed as "approximately 25". A VA discharge summary dated in October 2008, showed that the Veteran had been transferred from Fairfield Hospital. He was admitted there after he woke up feeling an electrical shock running through his body, but had a negative workup there. It was suggested that his symptoms might be related to his PTSD, but he denied ever having this shock-like sensation previously. He did not think he stopped taking his Sertraline in the days prior to this event, but he was not positive. He reported having nightmares, daytime flashbacks, hyperarousal, and a short temper since returning from Vietnam. In the past few weeks he had more trouble sleeping and felt like he had less patience when dealing with others than he previously had. He reported a depressed mood secondary to PTSD, as well as some fleeting suicidal ideation, without a plan, about a month ago after an argument with his wife. He reported he occasionally had suicidal ideation when he got very frustrated or when his PTSD symptoms got bad, but he denied any history of suicide attempts. He reported periods of paranoid thinking such as when helicopters fly over his house. He reported that the inpatient PTSD programs were the main things that have helped him, other than medication helping with sleep. It was noted that in 2005 he had neuropsychiatric testing in Miami which suggested mild impairment of his mental abilities due to compromised brain functioning, and that his performance pattern suggested bilateral cerebral dysfunction with greater compromise of the right frontal-parietal area. It was noted that this could be a slowly progressive condition, but the etiology was unclear, and he was currently on medication for memory. It was noted that on the first few nights of admission (to the VA hospital) he continued to sleep poorly and had frequent nightmares with occasional hallucinations, but as his medication was increased the nightmares became less frequent but he continued to have trouble falling asleep until Zolpidem was added and he did sleep much better. The etiology of the electrical sensations was unclear, although it was thought possibly to be SSRI discontinuation syndrome as the Veteran was unaware of medications he was taking prior to admission and may have inadvertently stopped taking Sertraline. His mood was initially noted to be a little depressed but as his sleep improved so did his mood. He occasionally became tearful when talking about friends he lost in Vietnam, but was otherwise euthymic in the days prior to discharge. It was noted that at no time during his stay did he have suicidal/homicidal ideation. On mental status examination at discharge, he was alert and cooperative, with less frequent lip-smacking and odd head movements. His speech was normal, his mood was pretty good, and he had a full range of affect, and was tearful at one point when talking about Vietnam. He denied current suicidal or homicidal ideation, hallucinations, and delusions. The discharge diagnoses included chronic PTSD and rule out SSRI discontinuation syndrome. The GAF score was 48. On a VA examination in November 2008, it was noted that the Veteran participated in group and individual therapy and took medication for his mental disorder symptoms, and that the medication helped him. The Veteran reported having trouble with sleeping, flashbacks, memories of his military tour, avoiding crowds and graveyards, irritability, startled response, and survivor's guilt. It was noted that these symptoms started when he returned from Vietnam and were moderate to severe on a daily basis. He had been married twice, and currently lived with his wife. He had four children, and described his family relationship as "not very well" and reported he did not have any friends. For activities and leisure pursuits, he reported he took care of dogs. He denied a history of suicide attempts. On objective examination, it was noted that he had disheveled clothes and persistent mannerisms, but he was oriented, cooperative, and his thought process and content were unremarkable. His affect was constricted and mood dysphoric. His judgment and insight were intact. He reported having sleep impairment that made him feel worn out the next day. It was noted that he had no delusions or hallucinations, no inappropriate behavior, no obsessive/ritualistic behavior, no panic attacks, and no homicidal or suicidal thoughts. He had good impulse control, was able to maintain minimum personal hygiene, and had no problems with activities of daily living. His memory was normal. It was noted that he was not currently employed, but was retired and his usual occupation was federal correctional officer and he had retired in 2002 because he was eligible by age or duration of work. The diagnoses included PTSD, and a GAF score of 55 was assigned. The examiner summarized that the changes in the Veteran's functional status and quality of life since his last examination included his social and interpersonal relationships, and recreation/leisure pursuits. The examiner opined that there was moderate impairment in his social and interpersonal relationships and recreation/leisure pursuits, due to PTSD symptoms. On the VA examination in June 2011, it was noted that the Veteran's social relations were limited to his wife and her close relatives, and that he reported he was a loner. His physical and leisure activities were limited to basic household chores, watching television, and taking care of his two dogs. On examination, his general appearance was described as "clean, bizarre clothes". His mood was anxious and depressed, and his affect was appropriate. He had no hallucinations or delusions, no panic attacks, and no homicidal or suicidal thoughts. He had fair impulse control and no episodes of violence, but was irritable. With regard to whether the Veteran was able to maintain minimum personal hygiene the examiner indicated "no", but also noted that the Veteran had no problems with activities of daily living. His PTSD symptoms included: recurrent and intrusive distressing recollections; recurrent distressing dreams; efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; markedly diminished interest or participation in significant activities; difficulty falling or staying asleep; and an exaggerated startle response. It was noted that prior to 2003, when PTSD was diagnosed, the Veteran was working, had a family, and had a very productive life, but that changes were seen after 2003 and he became depressed and anxious. The examiner noted that the Veteran's mental disorder was controlled with medication, that during the last year there had been no crisis hospitalization or significant change in medication, that he was doing "just fine", and that his GAF score was 66, which was compatible with a mild condition. It was also noted that his mental condition was stable, chronic, and without crisis. The examiner noted that the Veteran had retired in 2003, after a very productive occupational life, but that his signs and symptoms of PTSD were interfering with his social ability, leisure activities, and interpersonal relationships. The prognosis for improvement of his psychiatric condition and impairments in functional status was listed as "guarded". The examiner responded "no" to the following questions: whether there was total occupational and social impairment due to PTSD signs and symptoms; whether PTSD signs and symptoms resulted in deficiencies in the judgement, thinking, family relations, work, mood, or school; whether there was reduced reliability and productivity due to PTSD symptoms, whether there was an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning; and whether there were PTSD signs and symptoms that were transient or mild and decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner concluded that the Veteran's PTSD symptoms were controlled by continuous medication. On a VA general medical examination in October 2011, on the psychiatric assessment, it was noted that the Veteran had a normal affect, mood, and judgment, had no obsessive or inappropriate behavior, and had no hallucinations or delusions. The examiner was asking to discuss the Veteran's functional impairment and the types of employment activity that would be limited because of his service-connected physical disabilities. The examiner opined that based solely on the service-connected ischemic heart disease and other cardiac conditions listed, the Veteran was unemployable in a job that required strenuous activities such as his previous one as a custody officer. The examiner noted that custody officers were sometimes required to exert force to restrain inmates. The examiner opined that the Veteran was not able to obtain and secure a financially gainful job, or even a sedentary type job, because of repeated dizzy spells related to his heart rhythm. On a VA psychology note dated in December 2011, it was noted that the Veteran was well groomed and had an anxious mood with congruent affect. No suicidal or homicidal ideas, plan or intention were reported, and no memory and concentration difficulties were evident. The assessment was that his symptoms were consistent with diagnosis of PTSD, and he reported nightmares continued to be present. No significant improvement was observed, and it was noted that the Veteran's PTSD symptoms continued to negatively impacting his daily routine and interpersonal relationships, and that anxiety seemed to be exacerbating PTSD symptoms. A GAF score of 45 was assigned. A VA psychiatry noted dated in May 2012 showed that the Veteran reported sleeping problems and worsening of nightmares. He also reported feelings of sadness and depression, crying spells, isolation, anhedonia, as being worst lately, and his PTSD symptoms were still present, including sleeping problems, tiredness, irritability, and anger, and feelings of helplessness and hopelessness were also present. He had poor tolerance to daily stressors, and intrusive thoughts regarding traumatic events of war. No suicidal or homicidal ideas verbalized. On mental status examination, he had a depressed mood with congruent affect, and memory and concentration difficulties were evident. The assessment was that his PTSD symptoms had been somewhat worse lately, maybe related to the death of his father-in-law. A GAF score of 45 was assigned. The Veteran contends that, effective from April 12, 2013, he should be entitled to a higher rating for his PTSD, which has been evaluated as 70 percent disabling pursuant to 38 C.F.R. § 4.130, DC 9411. He has reported that his PTSD caused him to suffer various symptoms including depression, anxiety, sleep problems, insomnia, nightmares, flashbacks, intrusive thoughts, isolating behaviors, hypervigilance, and anger issues. With regard to occupational impairment, while he contends his psychiatric disability affected his ability to work, the record reflects he retired from his job as a federal corrections officer in 2003. Thus, although he has had difficulty with employment, he maintained a period of employment as a corrections officer for approximately 25 years, and, moreover, his work difficulties do not appear to be solely a result of his service-connected PTSD. In a VA psychology note dated April 12, 2013, it was noted that the Veteran came in for a psychotherapy session. On mental status examination he was well groomed , cooperative, and had good eye contact. He was anxious and had an irritable mood with congruent affect. He had no delusions or suicidal or homicidal ideas, plan or intention reported upon direct questioning. No memory or concentration difficulties were evident. The examiner assessed that the Veteran's symptoms were consistent with diagnosis of PTSD. The Veteran expressed irritability that exacerbated while in the waiting room due to a television program, and the Veteran's wife indicated he was more easily irritated for a few months now and that this had an impact on their relationship. The importance of anger management was stressed with Veteran, who was reportedly receptive to feedback. The examiner noted no significant improvement was observed and that PTSD symptoms continued to negatively impact his daily routine and interpersonal relationships. It was also noted that the Veteran's anxiety management continued to be deficient. The impression was PTSD, and a GAF score of 45 was assigned. A VA psychiatric progress note dated in August 2013 showed that the Veteran came to the clinic accompanied by his wife. He reported he had been more down than usual, and his wife reported he had been somewhat quieter and sometimes in his own world. On direct questioning, the Veteran reported there were times when he wished to be dead and that there had been times in the past that he had thought about suicide, but denied those intentions at that time. The Veteran's wife reported that she was with him most of the time and that if he verbalized any ideas of that she would take action. There were no perceptual disturbances reported, and the Veteran's nightmares and flashbacks continued to be prominent. On mental status examination, he had a depressed mood with congruent affect, and memory and concentration difficulties were evident. He had superficial insight and fair judgment. The GAF score remained at 45. On the VA examination in July 2014, the reported he had been married to his second wife for 10 years and denied separations or pending divorces. He reported he became frustrated and angry with his wife and became verbally aggressive but threatening or engaging in domestic violence. He reported having one friend, J.M., in Massachusetts that he saw once every two years, but otherwise had no friends. He reported that his wife and 2 dogs were his primary social contacts. He had no hobbies other than working in his yard and taking care of his pets. He reported he had 4 adult children, and he did not see his children or grandchildren often. He stated he has one sister in Ohio whom called him every once in a while, but otherwise he had no extended family contact. His wife reported he was short tempered and did not like to be in crowds, and the only thing he liked to do was be by himself with his dogs, watch television, and sit around a lot. She indicated it was like he was not in the present and was back in Vietnam, and that his sleep was disturbed by "by moaning, crying out names", even though he took medication regularly. His wife reported he did not have a very good relationship with his children, and noted that he distanced himself from her children. She also reported he did not communicate well with her, and that he was a loner. She reported she did most of the housework and hired people for the yard because the Veteran had low energy and fatigues easily, and she also noted that she must "push him" to change clothes or maintain hygiene. With regard to his occupational history, the Veteran reported he had been a federal correctional officer for 26 years, and that he worked for two federal prisons, and retired in 2002. He reported he liked the action and was a "high stress person" and was able to work for 26 years for the federal system. He denied having any poor work performance in his federal prison job, and noted "they loved aggressive people." He reported nightmares of combat that interfered with his sleep "4 or 5 times a week" and that he had anger issues every day and fixated on how others wrong him. He reported having panic attacks, that he prefers to stay by himself, that he avoids crowds, and that he has flashbacks when he is coming in/out of sleep or when he turns around quickly and sees out of his peripheral vision of "friends who died in Vietnam". He reported problems with concentration/memory. On mental status examination he had good hygiene, and his mood was dysphoric. He was cooperative and maintained good eye contact. His affect was irritable. He denied command, auditory hallucinations, but noted he occasionally thought he saw people, who he served with and were killed, out of peripheral vision or when going into/out of sleep. He was suspicious of others and did not trust people. He reported he last thought of suicide a "couple years ago when feeling bad" and was upset about family relationships at that time. He denied suicidal and homicidal plan or intent. His memory was intact and his attention was fair to good and judgment was fair as he partially understand outcome of behavior. The examiner opined that the Veteran continued to meet the DSM-5 criteria for a diagnosis of PTSD, chronic, that was of moderate impairment (at times ranging transiently into more severe social deficits) in regards to subjective distress and social functioning. The examiner noted the Veteran denied any occupational impairments during his career, and that his vigilance and aggressivity likely allowed him to function well as correctional officer, though this also likely deteriorated relationships with others in the family and in potential social contacts. Received in November 2015, along with an appropriate waiver of initial RO review, were statements from the Veteran and his wife, and a private vocational assessment. Of record is a Vocational Assessment dated in October 2015, prepared by A.J., who practiced in the field of vocational rehabilitation since 2002, was a Certified Rehabilitation Counselor as well as a vocational expert witness, and who had interviewed the Veteran and reviewed the record. In the Vocational Assessment, A.J. opined that the Veteran "has been unable to maintain a substantially gainful occupation due to his service connected disabilities since leaving his position in January 2003," and that "his symptoms have resulted in an ability to attend to basic work functions and resulted in him being unable to maintain substantially gainful employment". In the Veteran's statement describing the severity of his PTSD symptoms and the impact on his functioning, dated in August 2015, he reported struggling with PTSD symptoms since his discharge from service, which had worsened over time, including anxiety, nightmares, flashbacks, anger/irritability, loss of concentration, panic attacks. He reported he would prefer to never leave the house due to his anxiety and panic attacks, that he was hypervigilant, that he struggled with chronic anger and irritability which affected his relationship with his wife, that he got frustrated over his inability to concentrate, and that he struggled with nightmares and lack so sleep since service. He claimed he worked as a corrections officer from 1977 to January 2003 and that he had to retire early because he could no longer handle his PTSD symptoms and worried about the impact of his symptoms on his employment. He claimed he suffered with PTSD symptoms throughout his employment, but never suffered negative consequences because a corrections officer was allowed to be angry, aggressive, and confrontational. He reported he struggled with fatigue at work because of his nightmares, and that his job provided him enough adrenaline to keep going, but that this type of work only increased his anxiety and hyperalertness. He also claimed he had problems with his startle response, panic attacks, anxiety, and anger while at work. He claimed he was did not network with people, would tell the truth, was easily irritated and hated being around people schmoozing, and claimed that was likely why he ever got promoted. He indicated that when his time for retirement started approaching, he decided to retire because he was struggling to manage his symptoms, especially his anger and anxiety. In her statement, dated in August 2015, the Veteran's wife reported she had known the Veteran since 2002, and that when she first met him she did not realize the extent of his problems with PTSD. She reported that he was more withdraw than she realized in the beginning and that it was very hard to get him to leave the house, and that he was not comfortable around people and tended to make other people uncomfortable. She indicated it was easier for him to just avoid people, and that he was always on guard, and that if someone came to visit he would go down in the basement and not socialize. She reported the Veteran was always anxious, always living in the past, and always acting like someone was going to attack or try to come in. She described an incident where she tried to get him to go to the commissary with her, but he ended up having a panic attack and sitting in a corner with his head between his legs. She reported that they were limited where they could go in public, and that the Veteran would only go to lunch and during hours there were likely to be few people around. She reported he was angry all the time and that due to his anger and anxiety he just stayed home and watched television, and that sometimes he just sat and stared into space. She described his nightmares as occurring three to four times a week, and that he would scream in his sleep and would lash out at her. She reported he did not take care of himself, and that if she was not there he would not bathe regularly, change his clothes, shave, or get his hair cut. She claimed that based on her observations, the Veteran would not be able to work because of his PTSD issues. She indicated that when she met the Veteran he was working but near retirement, and that she was not sure how he lasted so long as he did besides his seniority because he was very difficult to deal with due to anger and anxiety. Analysis The evidence of record, reflects that the Veteran received ongoing therapy and medication for his PTSD. Additionally, the Veteran and his wife have reported many symptoms related to his PTSD, to include, but not limited to, panic attacks, short-term memory problems, depression, anxiety, ongoing sleep problems, intrusive thoughts, avoidance behaviors, difficulty concentrating, detachment from others, restricted range of affect, frequent rumination, limited energy, thoughts of death, but no active plan or intent, hypervigilance, exaggerated startle reflex, and increased alcohol consumption. With regard to the criteria for a 70 percent rating for PTSD, the competent evidence of record for the entire appeal period shows that the Veteran's PTSD did cause occupational and social impairment with deficiencies in most areas such as mood, thinking, judgment, family relations, school and work during this period. Thus, for the period prior to April 12, 2013, an increased rating to 70 percent is warranted. However, for the entire appeal period, from June 24, 2002, a total schedular rating is not warranted. Although he retired from his long time employment as a federal corrections officer in 2003, and it appears his PTSD and other physical problems have all affected his employment, in light of the grant of a TDIU rating below, due solely to his service-connected PTSD, it can be said that the Veteran has experienced total occupational impairment due to his PTSD symptoms. With regard to social impairment, however, while the Veteran has clearly had difficulty in this area, the evidence of record shows he has a supportive relationship with his wife and has at least one friend who lived out of state. Further, while the VA examiners acknowledged the Veteran's social problems, there was no conclusion that the Veteran had total social impairment due to his PTSD. A review of the competent evidence of record for the appeal period shows that the Veteran's PTSD does not approximate findings supportive of a 100 percent rating. 38 C.F.R. § 4.7. Specifically as to the rating criteria in question, on the VA examination reports and treatment records there was no showing of gross impairment in the Veteran's thought processes or communication. While it was noted that the Veteran had problems with concentration, no thought disorder or speech problems were noted, and he was always found to be alert and oriented. His insight, judgment, and abstraction ability were assessed as fair, and he denied delusions or hallucinations. While he reported he occasionally thought he saw people, who he served with and were killed, out of peripheral vision or when going into/out of sleep, he denied command and auditory hallucinations. While he reported having suicidal thoughts, the evidence of record does not show that was in persistent danger of hurting himself or others, because while he struggled with anger and irritability, he reported no homicidal thoughts and was able to somewhat control his temper by avoiding people/situations. With regard to the Veteran's ability to perform activities of daily living, including maintenance or personal hygiene, the Board notes that on VA examinations there have been no frequent problems noted with his grooming. While his wife indicated she had to remind him to bathe, change clothes, etc., there has been no indication that he has not taken care of himself. Further, the competent evidence of record has not shown the veteran to be disoriented to time and place. On the contrary, he has repeatedly been found to be alert and oriented, and VA evaluations have not noted any memory problems. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his psychiatric condition, and acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned rating reflects. Medical evidence is generally required to address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for those purposes. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, the competent medical evidence offering detailed and specific determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the psychiatric symptoms on appeal; further, the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The evidence as a whole, dated from June 24, 2002 to the present, demonstrates that the Veteran's PTSD did not approximate the criteria for a 100 percent rating, and he is not totally impaired in social and occupational functioning from PTSD. Rather, his symptoms more nearly approximate the criteria for a 70 percent rating as he has been found to have some deficiencies in work, family relations, judgment, thinking, mood, as well as depression, difficulty in adapting to stressful circumstances, and problems with establishing and maintaining relationships. Thus, the record reflects that the Veteran's disability picture from his PTSD more nearly approximates the criteria for the 70 percent rating, rather than 100 percent. 38 C.F.R. § 4.7. And while the Veteran experiences a myriad of other symptoms due to his PTSD which are not specifically listed in the criteria for a 100 percent rating, the Board notes that the most severe of these symptoms appear to be sleep difficulties, nightmares, irritability/anger, isolating behavior, depression, hypervigilance, panic attacks, and anxiety; however, even considering the magnitude of these symptoms as being moderate to severe, the Board does not find these symptoms to be of such severity, frequency or duration to produce total social or occupational impairment. Mauerhan, supra. With regard to GAF scores, which is one factor to be considered in determining the degree of impairment caused by the Veteran's PTSD, VA treatment records show a range GAF scores, with the majority being in the 45 to 55 range, which suggests serious symptoms or any serious impairment in social or occupational functioning. Thus, the Board concludes that the preponderance of the evidence of record from June 24, 2002, militates against finding that the Veteran's disability picture due to his PTSD approximates the criteria for a 100 percent schedular rating. 38 C.F.R. § 4.7. Considering all evidence of record, the Board finds the Veteran's level of symptomatology due to PTSD, is consistent with a finding of moderate to severe occupational and social impairment with deficiencies in most areas, which warrants the current 70 percent rating assigned. See Fenderson, supra. The evidence of record does not show total occupational and social impairment; thus, the Board finds that the criteria for a 100 percent schedular rating have not been met. Accordingly for the period prior to April 12, 2013, the Board finds that the preponderance of the evidence supports an increased rating of 70 percent for the Veteran's PTSD, and that a rating in excess of 70 percent for PTSD must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, supra. With regard to the claim for higher ratings for PTSD, the Board notes that according to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b) ] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Accordingly, referral for consideration of 38 C.F.R. § 3.321(b)(1) is not warranted in this case. IV. TDIU Rating, Effective Prior to February 25, 2010 The Veteran contends he should be entitled to a TDIU rating, effective from January 3, 2003, the date he last worked, or, alternatively, that he should be entitled to a TDIU rating since January 3, 2003, due to his PTSD. As noted above, a 100 percent rating was granted for the service-connected ischemic heart disease, effective from February 25, 2010; therefore discussion regarding entitlement to a TDIU is limited to the rating period on appeal prior to that total rating. VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in adjudicating a TDIU request, VA must take into account the individual Veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability. Given the Board's grant of a 70 percent evaluation for PTSD back to June 24, 2002, in addition to this rating, prior to February 25, 2010, the Veteran was in receipt of a 10 percent rating for ischemic heart disease, effective since December 22, 2008; a 10 percent rating for bilateral tinnitus, effective from August 30, 2004; and a 0 percent rating for bilateral hearing loss, effective from August 6, 1977. Thus, the Veteran met the threshold criteria for an award of TDIU under 38 C.F.R. § 4.16(a) (2015). Turning now to the relevant evidence of record, the Board notes that while VA examiners have opined that the Veteran's PTSD caused occupational impairment, none have opined that his PTSD caused total occupational impairment. In 2014, the VA examiner noted the Veteran denied any occupational impairments during his career, and that his vigilance and aggressivity likely allowed him to function well as correctional officer, though this likely deteriorated relationships with others in the family and in potential social contacts. In his August 2015 statement the Veteran has contended he would be unable to work due to his service-connected PTSD and related symptoms. Further, on his TDIU application (received in February 2011), he indicated that his PTSD, ischemic heart disease, and tinnitus, precluded him from securing or following any gainful occupation. He stated that he last worked full-time in January 2003, and that in January 2003 he became too disabled to work. He also indicated that he did not leave his last job due to disability, and that he had not tried to obtain employment since he became too disabled to work. As noted above, of record is a Vocational Assessment report, in which the vocational expert, A.J. provided a list of the very basic requirements to maintaining substantially gainful employment, and opined that the Veteran would have significant difficulty with many of these requirements while trying to work, particularly due to engaging in outbursts or arguments on the job. A.J. also noted the Veteran's statements regarding his employment as a corrections officer, including panic attacks resulting in him needing to flee the area or take unscheduled breaks, which resulted in time off task; and his only sleeping 3-4 hours per night due to nightmares which would make it difficult for anyone to function and maintain a regular schedule. A.J. found it surprising that the Veteran was not fired based on his description of events that took place while working as a corrections officer, but also noted he was reassigned to other tasks or relieved of his duties on several occasions and that it was likely that his employer was trying to accommodate him due to his long term employment or possibly because of his military service. In conclusion, A.J. opined that the Veteran "has been unable to maintain a substantially gainful occupation due to his service connected disabilities since leaving his position in January 2003," and that "his symptoms have resulted in an ability to attend to basic work functions and resulted in him being unable to maintain substantially gainful employment". Thus, in light of the evidence for and against the claim for a TDIU rating prior to February 25, 2010, the Board finds that the evidence is in relative equipoise as to whether a grant of TDIU is warranted under 38 C.F.R. § 4.16. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Based on the competent evidence, and resolving all doubt in the Veteran's favor, the Board concludes that his service-connected PTSD precluded all types of employment for the rating period on appeal prior to February 25, 2010. Id. In that regard, the Board notes that the record reflects the Veteran has reported being unemployed since he retired in January 2003. Accordingly, a TDIU rating predicated on the service-connected PTSD is granted for the rating period prior to February 25, 2010. ORDER Service connection for tonsillar squamous cell carcinoma with metastasis, to include residuals claimed as scarring, muscle damage, and nerve damage, is granted. Prior to April 12, 2013, a rating of 70 percent for PTSD is granted, subject to the law and regulations governing payment of monetary benefits. Effective from April 12, 2013, a rating in excess of 70 percent for PTSD is denied. Prior to February 25, 2010, a TDIU rating is granted, subject to the law and regulations governing payment of monetary benefits. ____________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs