Citation Nr: 1732474 Decision Date: 08/10/17 Archive Date: 08/23/17 DOCKET NO. 07-06 171 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for persistent depressive disorder (previously characterized as anxiety disorder and posttraumatic stress disorder (PTSD)) (hereinafter "psychiatric disability"), for the period prior to May 21, 2015. 2. Entitlement to a rating in excess of 70 percent for a psychiatric disability, for the period beginning on May 21, 2015. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service connected disabilities, for the period prior to May 21, 2015. REPRESENTATION The Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD V-N. Pratt, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1958 to July 1962. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York, which granted service connection for PTSD and assigned an initial 30 percent rating, effective February 8, 2006. In a March 2008 rating decision, the RO recharacterized the service connected psychiatric disability as anxiety disorder, finding it was a progression of the prior diagnosis of PTSD, as indicated in the March 2008 statement of the case, and continued the initial 30 percent disability rating. In April 2009, the Veteran testified at a Travel Board hearing. A transcript of this hearing is of record. In a July 2017 correspondence, the Veteran was notified that the Veterans Law Judge who conducted his hearing in April 2009 was no longer employed by the Board and was provided with an opportunity to schedule another hearing. Later that same month, the Veteran waived his right to appear at another hearing before the Board and requested that the case be considered based on the evidence of record. In August 2009, the Board remanded the matter for further development, and also inferred a claim for TDIU back to the AOJ for adjudication, as part of the claim for an increased rating for an acquired psychiatric disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board also remanded a claim for service connection for a back condition. In a December 2016 rating decision, the RO granted service connection for severe arthrosis and degenerative disc disease of the lumbar spine. Since this was a full grant of the benefit sought as to the claim for service connection for a back condition, this issue is no longer on appeal. In a December 2016 rating decision, the RO recharacterized the service-connected disability as persistent depressive disorder, and granted a higher 70 percent rating, effective May 21, 2015, and granted a TDIU, effective May 21, 2015. While the RO has assigned a higher rating for the Veteran's service-connected psychiatric disability during the pendency of this appeal, because higher ratings are available before and after May 21, 2015, and the Veteran is presumed to seek the maximum available benefit, the claim for higher initial ratings for a psychiatric disability remains on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); AB v. Brown, 6 Vet. App. 35 (1993). Further, because the claim for a TDIU is part of the claim for a higher initial rating for a psychiatric disability, this is only a partial grant of the benefit sought, and the issue of entitlement to a TDIU prior to May 21, 2015 remains on appeal before the Board. In December 2016, the Veteran executed a new power-of- attorney (VA Form 21-22), designating Disabled American Veterans as his representative. The Board recognizes the change in representation. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to a rating in excess of 70 percent for a psychiatric disability, from May 21, 2015, and entitlement to a TDIU for the period prior to May 21, 2015 are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT For the period prior to May 21, 2015, the Veteran's psychiatric disability more nearly approximated occupational and social impairment with reduced reliability and productivity. Occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships are not demonstrated. CONCLUSIONS OF LAW Resolving all reasonable doubt in favor of the Veteran, the criteria for an initial 50 percent rating, but not higher, for a psychiatric disability, for the period prior to May 21, 2015, have been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code (DC) 9400 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 (2016). Neither the Veteran nor his/her representative have raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Initial Rating for the Period Prior to May 21, 2015 Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2016). When a question arises as to which of two ratings applies under a particular DC, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7 (2016). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2016). The Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1 (2016); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). From the period of February 8, 2006 to May 21, 2015, the Veteran was rated at 30 percent for an anxiety disorder (previously diagnosed as PTSD, and subsequently, diagnosed and rated as persistent depressive disorder), pursuant to 38 C.F.R. § 4.130, DC 9400 (2016). All psychiatric disabilities are generally applicable to a general rating formula. In his Post-Remand Appellate Brief, the Veteran asserted that the evidence of record establishes a history of persistent depressive disorder preventing him from employment and that therefore, an entitlement to an increased evaluation of at least 50 percent, prior to May 21, 2015, is warranted. Pursuant to the General Rating formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, 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 per week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A rating of 100 percent is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The symptoms noted in the rating schedule are not intended to constitute an exhaustive list, but rather, are designed to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. Id. When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA will assign a rating 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. 38 C.F.R. § 4.126 (a) (2016). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (b) (2016). Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), a GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown , 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. A March 2006 VA psychiatry note reflects that the Veteran reported that he always avoided being in a boat or being close to water and that he had recently gotten into a family argument because he did not want to go on a cruise vacation. He reported feeling stressed by family conflict, and further indicated that he was taking his medication daily, which made him feel less anxious and irritable. He had sleep disturbances, nightmares and recurrent and intrusive recollections of an accident while on board a ship. On mental status examination, he was alert, oriented and cooperative. His speech was spontaneous, and goal directed with a normal rate, tone and volume. The Veteran denied having any suicidal ideation or auditory/verbal hallucination, his mood was slightly anxious, with constricted affect, cognition grossly intact, and no evidence of acute delusion or perceptual disturbance. The impression was chronic PTSD and a GAF score of 55 was assigned. A July 2006 VA PTSD screen reflects that the Veteran has nightmares, avoids situations that reminds him about frightening experiences in the past, is constantly on guard, watchful or easily startled and felt numb or detached from others, activities, or his surroundings. A July 2006 VA psychiatry record reflects that the Veteran's grooming and hygiene was normal. He was stable and tolerating his treatment and wanted to contined that same medications. Attention, concentration, memory, and thought processes were normal. He denied suicidal and homicidal ideation, plan and intent. He denied hallucinations, feelings of hopelessness and helplessness. His judgment and insight was fair. Impulse control was good. The diagnosis was PTSD and a GAF score of 55 was assigned. A July 2007 VA psychiatry note reflects that the Veteran had not taken his medications regularly as prescribed. The Veteran reported being prone to distraction, with difficulty being effective in things to do at home. He feels anxious and remains socially withdrawn, has difficulty completing tasks, feels unmotivated to do things with persisting anxious mood, and has conflicts with spouse. A March 2008 VA examination report reflects that the VA examiner described the Veteran as a vague and inconsistent informant, and that the employment history documented in the VA examination should be regarded as tentative. The VA examiner reported that according to the Veteran, his last full time job was with UPS in customer service, and that he retired sometime in the 1990s after eighteen years with the company. The VA examiner further indicated that the Veteran reported subsequent part time employment as a salaried employee of a window manufacturer. The VA examiner explained that the Veteran had difficulty with describing his job duties, hours at work and reasons for leaving the job. Additionally, the VA examiner indicated that the Veteran did not directly attribute his unemployment for the previous five years, to psychiatric symptoms, and that because of the vagueness of the Veteran's recollection, it was impossible for him to form an opinion about the effects of any psychiatric disorder on his past occupational functioning. The Veteran stated that he spent his time in his room watching black and white movies, helping to care for his wife and enjoying visits from his grandchildren. The Veteran was unable to describe other activities, but the VA examiner noted that his appearance suggested adequate maintenance of activities of daily living. A history of his psychiatric care reflects that he began regular outpatient treatment at the VAMC Northport in 2005, where he presented complaints of depressed mood associated with leg pain, and subsequently, complained of nightmares about events aboard the Intrepid in 1959. At the time, he was taking Sertraline, in which he complained that it had side effects that he felt were ineffective. The VA examiner noted that the October 2006 physician questionnaire that endorsed severe psychiatric impairment was inconsistent with contemporary treatment notes. On mental status examination, the Veteran was casually dressed, appropriately groomed, and alert and oriented in all spheres. His mood is mildly dysphoric; affect is congruent with thought content. He hinted at, but did not explicitly report, suicidal ideation, and the Veteran did not provide any reports of homicidal ideation, intent or plan. Although the Veteran reported hypersommnolence, he also reported middle insomnia. He did not report any panic attacks, phobias, obsessive thoughts or rituals that interfered with functioning, although he refuses to go on boats. Judgment and insight were present. Testing was performed, and the examiner found it was invalidated by the Veteran's endorsement of an unusually large number of extreme items in the deviant direction; an indiscriminate and exaggerated response pattern was probable. The diagnosis was anxiety disorder, not otherwise specified which the examiner related as a continuation of the service connected PTSD and assigned a GAF score of 65. In an April 2008 VA Form VA 9, the Veteran stated that he was getting confused a lot; believed he had gotten worse as time went on; reported that panic attacks were getting more frequent, at least 3 to 4 times a week; and that he lost interest in most things and indicated that all he wanted was "to be left alone." He further indicated that he did not like to talk to people and sometimes his family, because he knows "that they laugh at [him] behind [his] back." A February 2009 VA psychiatry medication management record reflects that the Veteran reported he was doing much better and had gained better coping skills. He was not taking any psychotropic and reported he was doing fine without it. He was spending time with his family, his children and grandchildren. He enjoys daily activities despite episodes of worry. There was no evidence of acute distress. On mental status examination, grooming and hygiene were normal, mood was normal and affect was appropriate, and attention, concentration, memory and thought processes were normal. The Veteran denied suicidal and homicidal plan, intent, or ideation. Judgement, insight and impulse control were good. The diagnosis was PTSD and a GAF score of 65 was assigned. It was noted that the Veteran was not interested in mental health follow-up for now and would walk in as needed. At an April 2009 hearing, the Veteran testified that he suffered from severe panic attacks up to three times a week. He also indicated that he has one friend that contacts him every once in the while, but he did not have a desire to meet new friends and wanted to be by himself sometimes. In stating that, the Veteran further indicated that he considers himself an isolated individual. In discussing his relationship with his family, he stated that he loves his grandkids very much, but that his physical disabilities prevent him from interacting with them as he would like. Additionally, he reported that he is unable to attend fishing trips that involve going on a boat because of what happened to him service. In an October 2009 letter, a former employer stated that he had known the Veteran years earlier as a top salesperson in the home improvement industry, but after a few days had realized that he had changed. The Veteran was in physical pain all the time. He was irritable and sometimes violent. His judgment and knowledge was an issue. He forgot everything about selling. Even his speech was erratic. He would go into a panic attack. He was very unstable. So, the prior employer stated he had to let the Veteran go. In a separate October 2009 letter, another former employer noted that from 2000 to 2006 the Veteran was hired to sell home improvements. He started as a very productive salesman, but as time went by, his sales drastically dropped off. He began to forget basic home improvement knowledge. In addition, he became irritable, very depressed, was rude with customer and showed signs of violence towards other employees and customers. It was noted that the Veteran admitted that he was getting panic attacks when he was with customers. He became more and more distant and left on his own accord. A March 2010 VA examination report notes that the Veteran refuses psychiatric medications but sees his outpatient psychiatrist every three months for help managing anxiety. He reported good results with a breathing exercise to reduce anxiety or anxiety attacks. A review of the Veteran's medical history reflects a GAF score of 65, which was recorded in November 2009. The VA examination also indicates that he had been assigned scores of 60 - 65 over the previous two years, and there were no reports of hospitalization since his previous examination in 2008. The VA examiner indicated that the Veteran presented a confusing work history during his previous VA examination, but that his claims file had since presented a chronological work history that his sons had put together. The VA examination report indicates that the Veteran worked as a manager with United Parcel Services for twenty-two years and retired on his pension in 1986, and subsequently, he worked as a window salesman. The VA examination report also noted that a letter from his last employer suggested that the Veteran's work performance deteriorated as he began to forget basic tenets of the business. Additionally, the VA examination report indicated that the Veteran apparently told his employer that he was having panic attacks and was suffering from back pain. The VA examination report also indicated that he had a private contracting business in 2007/2008, which apparently ended because of back pain and memory impairment. The Veteran stated that he had not worked since that time for both physical and psychological reasons. A review of the Veteran's present medical, occupational and social history from the preceding year reflects that Veteran described his relationship with his wife and sons as stable, and indicated that they were helping him with his finances. The Veteran also indicated that they took the car keys away from him because he was getting lost when he drove to familiar destinations. He is unable to describe any enjoyable activities. The Veteran did not complain of flashbacks or nightmares. He reported having increasingly severe memory impairment, resulting in irritability and anxiety. The Veteran also reported having panic attacks or episodes of anxiety, which he controlled with breathing techniques learned from his psychiatrist and he is depressed. The VA examiner noted that although the Veteran indicated that he was having panic attacks three times a day, he also indicated that he could not remember when his last panic attack occurred prior to the exam, but that it was likely a week or two prior this VA examination. He also reported having difficulty with short and long term memory, which at the time was mild to moderate, and was present without remission for at least the previous seven or eight years. He also reported mild to moderate depression, likely present without remission on a daily or weekly basis since 2007 or 2008. The VA examiner concluded that the Veteran's memory impairment was at least as likely as not the most significant impediment to finding or maintaining gainful employment. Further, based on this presentation in the interview and results of a test of cognitive impairment, the VA examiner opined that the Veteran's memory problems are less likely as not related to his service-connected psychiatric diagnosis. The examiner commented that his memory impairment would make any occupation requiring concentration or contact with the public highly problematic. He furthered that the Veteran's reported depression and anxiety (symptoms associated with his service connected diagnosis) are less likely as not to preclude finding or maintaining gainful employment, based on contemporary assessments by his outpatient psychiatrist. The Veteran indicated significant social withdrawal as a result of his depression and anxiety. On mental status examination, the Veteran was casually dressed, appropriately groomed, alert and oriented in all spheres. He avoids eye contact when he describes panic attacks or depression. His hygiene was unremarkable and he displayed behavior appropriate to the interview setting. His mood was dysphoric and affect was congruent. The Veteran reported having "passive suicidal ideation" without intent or plan, but did not report homicidal ideation/intent/plan. His speech and thought process were essentially unimpaired, and he spoke fluently with normal intonation, rhythm, and volume, with linear and logical thinking that displayed no signs of formal thought disorder. The Veteran did not report any episodes of hallucinations or delusions, nor did he report any obsessions or phobias that interfered with normal functioning. Long term recall, short term recall, attention, and concentration were all mildly to moderately impaired. He reported possible panic or near panic attacks, effective controlled by breathing techniques. The Veteran reported disturbed sleep patterns due to back pain and nocturia. Judgment and insight are present. The VA examiner found that a brief test of cognitive impairment suggested that the Veteran was functioning in the mildly to moderately impaired range. The Veteran's cognitive impairment was diagnosed as cognitive disorder, not otherwise specified (NOS). The examiner opined that based on the his statements and his employer's observations, his forgetfulness and inability to remember previously well known facts as well as indications in this examination of difficulties with written expression, short term recall and spatial construction are less likely as not related to his service connected psychiatric disorder. The additional diagnosis of dysthymic disorder represented a continuation of the previously diagnosed generalized anxiety disorder. The assigned GAF score of 60, which according to the VA examiner reflected impaired short and long term recall, periodic confusion, and depressed mood, anxiety, panic or near panic attacks. A November 2010 outpatient note reflects that Veteran had a positive depression screen. The Veteran reported having "little interest or pleasure in doing things" nearly every day and that he was feeling down, depressed, or hopeless more than half the days. A July 2011 VA neurology record reflects that the Veteran was seen for the evaluation of memory impairment that began five years ago. He is forgetting things around the house, getting lost near the home and he felt that this is progressive. Some difficulties in comprehension and word finding were noted on examination. Neurological examination was normal. The Veteran was started on Aricept. An August 2011 VA medical record reflects that the Veteran had improvement in memory since being started on Aricept by neurology. It was recommended that the Veteran undergo neuropsychological testing, but the Veteran cancelled the psychology appointment. He stated that he has been seen by "psych" in the past for depression and feels he will not gain anything from more testing/treatment. It was noted that the Veteran has a history of depression without suicidal intent or previous attempts. He has not suicidal or homicidal ideation. The Veteran currently denies feeling depressed. He was assessed with depression/panic attacks - stable; memory impairment improved on Aricept. A June 2013 VA nursing record reflects that the Veteran underwent a screening for depression, at which time, when asked if he had little interest or pleasure in doing things or feeling down, depressed or hopeless, the Veteran responded "not at all." The Board has considered all the evidence of record in light of the criteria noted above, and finds that by, resolving all reasonable doubt in favor of the Veteran, his symptoms associated with his service-connected psychiatric disability more nearly approximate the criteria for a higher initial 50 percent disability rating for the period prior to May 21, 2015. 38 C.F.R. § 4.7 (2016). In granting an initial 50 percent disability rating, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In this regard, for the period prior to May 21, 2015, the Veteran's psychiatric symptoms were manifested, by: sleep disturbances, nightmares and recurrent and intrusive recollections of an accident while on board a ship, panic attacks, anxiety, depression, depressed mood, and social isolation. The Board finds that symptomatology more nearly approximates occupational and social impairment with reduced reliability and productivity, the criteria for a 50 percent disability rating. The Board has considered the rating criteria in the General Rating Formula for Mental Disorders and finds that the extent and severity of the Veteran's persistent depressive disorder more nearly approximated a 30 percent disability rating with an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, prior to May 21, 2015. The Board emphasizes that there is no period prior to May 21, 2015 where the evidence shows that the Veteran had suicidal intentions (other than one instance of a "passive suicidal ideation"); obsessional rituals which interfered with routine activities; speech which was 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); or an inability to establish and maintain effective relationships or more severe symptomatology such as to warrant at least the next higher 70 percent rating. The evidence of record does not show symptoms with deficiencies in most areas. Symptomatology commensurate with a 100 percent schedular evaluation, demonstrating total occupational and social impairment, is also not shown. The evidence does not show total occupation and social impairment. The Board notes that the Veteran has reported significant memory problems; however, the March 2010 VA examiner opined that the Veteran's memory problems are less likely as not related to his service-connected psychiatric diagnosis and have been associated with a separately diagnosed non service connected cognitive disorder. Further, the Veteran's symptoms of irritability are also associated with his cognitive disorder, and are therefore not considered in the evaluation of the severity of his service connected psychiatric disability. Furthermore, while the Veteran's reports of some social isolation which would suggest some difficulty in establishing and maintain effective work and social relationships, it is not productive of the complete inability to do so and thus is not otherwise indicative of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, as is required for the next higher rating of 70 percent. Bowling v. Principi, 15 Vet. App. 1, 11 (2001); Vazquez-Claudio v. Shinseki, 713 F. 3d 112, (Fed. Cir. 2013) (70 percent rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency, or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation). In fact, the Board notes that the Veteran has reported effective relationships with his children and grandchildren. Therefore, the Board finds that the preponderance of the evidence is against a finding of a greater level of occupational or social impairment. In addition to the absence of most of the symptoms listed as characteristic of occupational and social impairment with deficiencies in most areas, criteria for a 70 percent rating, the Board also notes that the assigned Global Assessment of Functioning Scale (GAF) scores ranging from 55 to 65 have most consistently been assigned during the entire appeal period, and alone, they do not support the assignment of any higher rating during the period in question. According to DSM-IV, GAF scores ranging between 61 and 70 denote 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 when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores from 51 to 60 are indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupation, or school functioning (e.g., few finds, conflict with peers or co-workers). The Board reiterates, that the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the rating issue. Rather, they must be considered in light of the actual symptoms of the Veteran's disability, which provide the primary basis for the rating assigned. 38 C.F.R. § 4.126 (a)(2016). While the assignment of a GAF score of 65 in a February 2009 VA medical record would suggest that a lower 30 percent rating may be warranted, the descriptions of the Veteran's symptomatology are the most accurate guide to identifying the severity of the psychiatric condition, and the narrative description is more persuasive than an examiner's one-time snapshot at the moment of an examination through the GAF score. 38 C.F.R. § 4.126 (a) (2016). In reaching the above conclusions, the Board has considered the Veteran's statements the severity of his psychiatric symptoms. As a lay persons, he is competent to report on factual matters of which he has first-hand knowledge, such as experiencing an increased level of psychiatric symptomatology. Washington v. Nicholson, 19 Vet. App. 362 (2005). Thus, even with consideration of the Veteran's statements, along with the VA mental health records and examination reports and other probative evidence of record have consistently shown, that is by resolving all reasonable doubt in the Veteran's favor that his service-connected psychiatric disability has resulted in no more than occupational and social impairment with reduced reliability and productivity. In summary, by resolving all reasonable doubt in favor of the Veteran, the symptoms more nearly approximate the criteria for an initial 50 percent rating, but not higher, for his service connected psychiatric disability, prior to May 21, 2015. However, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 50 percent. 38 U.S.C.A. § 5107 (b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial 50 percent rating, but not higher, for service connected psychiatric disability, is granted, for the period prior to May 21, 2015. REMAND While the Board regrets further delay, additional development is necessary before a decision may be rendered on the issue of entitlement to a rating in excess of 70 percent for a psychiatric disorder, from May 21, 2015 and for entitlement to a TDIU for the period prior to May 21, 2015. The Board notes that a December 2016 Supplemental Statement of the Case (SSOC) reflects that the RO considered VA treatment records dated November 23, 2016 from the VA medical center (VAMC) in Northport. However, VA medical records associated with the claims file are only dated through June 4, 2015. Thus a remand is warranted to obtain outstanding VA medical records dated from June 2015 to the present and associate them with the claims file. With regard to the claim for a TDIU for the period prior to May 21, 2015, the Board finds that a retrospective medical opinion should be obtained. (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file, including from the VAMC Northport dated from June 4, 2015 to the present. 2. Obtain a retrospective medical opinion as to whether the Veteran was unemployable due to his service-connected disabilities, alone or collectively (psychiatric disability, lumbar spine disability, and left leg disability) prior to May 21, 2015. The Board noted that an in-person examination is only required if deemed necessary by the reviewer. The examiner should comment on the effects of the Veteran's service-connected psychiatric disability, lumbar spine disability and left leg disability, alone and collectively, on his ability to secure and follow a gainful occupation. In doing so, the examiner should comment on the Veteran's ability to function in an occupational environment and describe the functional limitations related to his service-connected psychiatric disability, lumbar spine disability and left leg disability. The opinion should be based on a review of all of the medical and lay evidence, and take into account the Veteran's education, training, and work history (but not his age or the impact of any nonservice-connected disabilities). The examiner should also consider October 2009 letters from the Veteran's prior employers. The examiner should set forth the complete rationale for all conclusions reached. After ensuring compliance with the above, readjudicate the claims remaining on appeal. If any benefit sought on appeal remain denied, issue a SSOC and allow the appropriate time for response by the Veteran or his representative. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ Lesley A. Rein Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs