Citation Nr: 1751742 Decision Date: 11/13/17 Archive Date: 11/22/17 DOCKET NO. 10-18 209A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to an effective date prior to May 27, 2014 for the assignment of an initial 50 percent rating for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Htun, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1990 to April 1990 and from September 1990 to June 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, which granted service connection for PTSD with alcohol abuse in remission and assigned a 30 percent rating, effective June 24, 2010, the date of claim. In January 2014, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge sitting in Washington, D.C. A transcript of the hearing is of record. In April 2014, the Board remanded this case for further development. In an August 2014 rating decision, the agency of original jurisdiction (AOJ) granted a 50 percent rating for PTSD, effective May 27, 2014. In a November 2014 decision, in pertinent part, the Board denied an initial rating in excess of 30 percent for PTSD prior to May 27, 2014, and in excess of 50 percent thereafter. Thereafter, the Veteran appealed the portion of the decision that denied an effective date prior to May 27, 2014 for the assignment of an initial 50 percent rating to the United States Court of Appeals for Veterans Claims (Court). In a June 2014 Joint Motion for Remand (JMR), the Secretary of VA and the Veteran (the parties) moved the Court to vacate the November 2014 decision with respect to such issue only, which was granted in a June 2015 order. The JMR determined that the Board failed to adequately consider the Veteran's January 2014 hearing testimony when determining that a 50 percent rating was not warranted prior to May 27, 2014. In this regard, the JMR noted that the Veteran did not challenge the determination in the November 2014 decision with respect to the denial of an initial rating in excess of 50 percent for PTSD, as of May 27, 2014, a rating in excess of 20 percent from March 24, 2008, for arthritis of the lumbosacral spine; and an initial rating in excess of 10 percent as of May 28, 2014 for radiculopathy of the left lower extremity. Therefore, those issues are no longer before the Board. In September 2015, the Board denied the Veteran's claim to an effective date prior to May 27, 2014, for the assignment of an initial 50 percent rating for PTSD. Thereafter, the Veteran again appealed the denial of his claim to the Court. In a February 2017 Memorandum Decision, the Court vacated the Board's September 2015 decision and remanded the matter for further adjudication. The case now returns for further appellate review. FINDING OF FACT It is not factually ascertainable that the Veteran's PTSD resulted in manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity prior to May 27, 2014. CONCLUSION OF LAW The criteria for an effective date prior to May 27, 2014 for the assignment of an initial 50 percent rating for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.321, 3.400, Part 4, including §§ 4.7, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective e date of the disability. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. Id; see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). In the instant case, the issue of entitlement to an initial higher rating for PTSD arises from the appeal of the initial evaluation assigned following the grant of service connection. Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under the VCAA with respect to this matter. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The record contains the Veteran's post-service reports of VA and private treatment, and VA examination reports. Moreover, the Veteran's statements in support of the claim, including his Board hearing testimony, are of record. The Board has carefully reviewed such statements and concludes no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. Additionally, the Veteran was afforded VA examinations in March 2011 and May 2014 to evaluate the severity of his service-connected PTSD. The Board finds that the VA examinations are adequate because, as discussed below, they were based upon consideration of the Veteran's pertinent medical history, his lay assertions, and current complaints, and because they provide detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). The Board accordingly finds no reason to remand for further examination. Moreover, in January 2014, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Office or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues; and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the January 2014 hearing, the undersigned noted the issue on appeal and information was obtained regarding the Veteran's contentions. Further, the undersigned requested further information concerning current symptoms as well as functional impairment, to include the impact on his daily life and employability. In addition, the hearing focused on the elements necessary to substantiate the Veteran's claim. The Veteran has not asserted that there was any prejudice with regard to the conduct of the hearing. Therefore, not only were the issues "explained... in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the Board remanded the case in April 2014 so that additional evidence could be obtained, to include a current VA examination. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. 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). Finally, the Board finds there was substantial compliance with the April 2014 remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). In particular, the Board in April 2014 directed the AOJ to obtain VA treatment records. Additional VA treatments were obtained dated from January 2010 to March 2014 and associated with the VBMS record. Further, the AOJ was also directed to schedule the Veteran for a VA examination. As noted above, the Veteran was afforded VA examinations in May 2014 to address the current severity of the Veteran's PTSD that is adequate for appellate review. Accordingly, the Board finds that there has been substantial compliance with the April 2014 Board remand directives and, therefore, no further remand is necessary. See Stegall, supra; D'Aries, 22 Vet. App. at 104 (2008). II. Analysis The Veteran is seeking an effective date prior to May 27, 2014 for the assignment of an initial 50 percent rating for PTSD. The assignment of effective dates of awards is generally governed by 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on a claim for service connection or for an increase of compensation "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore." 38 U.S.C.A. § 5110(a). The implementing regulation clarifies this to mean that the effective date of an award of service connection or for increase compensation "will be the date of receipt of the claim or the date entitlement arose, whichever is later." 38 C.F.R. § 3.400. This claim is subject to the more specific criteria under 38 U.S.C.A. § 5110(b)(2) and 38 C.F.R. § 3.400(o)(2). "The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C.A. § 5110(b)(2). The implementing regulation summarizes the criteria for an effective date of an award of increased compensation as the "[e]arliest date as of which it is factually ascertainable that an increase in disability had occurred if claim is received within 1 year from such date otherwise, date of receipt of claim." 38 C.F.R. § 3.400(o)(2). The Court has indicated that it is axiomatic that the fact that must be found, in order for entitlement to an increase in disability compensation to arise, is that the service-connected disability must have increased in severity to a degree warranting an increase in compensation. See Hazan v. Gober, 10 Vet. App. 511, 519 (1992) (noting that, under section 5110(b)(2), which provides that the effective date of an award of increased compensation shall be the earliest date of which it is ascertainable that an increase in disability had occurred, "the only cognizable 'increase' for this purpose is one the next disability level" provided by law for the particular disability). Thus, determining whether an effective date assigned for an increased rating is correct or proper under the law requires (1) a determination of the date of the receipt of the claim for the increased rating as well as (2) a review of all the evidence of record to determine when an increase in disability was "ascertainable." Id. at 521. In the instant case, the Veteran filed his claim for service connection for PTSD in June 2010. In a September 2011 rating decision, service connection for PTSD with alcohol abuse in remission was granted and an initial 30 percent rating was assigned, effective June 24, 2010, the date of claim. In an August 2014 rating decision, the AOJ granted a 50 percent rating for PTSD, effective May 27, 2014. Therefore, while the Veteran's claim was received on June 24, 2010, the AOJ determined that a factually ascertainable increased occurred on May 27, 2014, the date of a VA examination showing increased impairment in social and occupational functioning. Therefore, with regard to the Veteran's current effective date claim, the inquiry before the Board is whether there was a factually ascertainable increase in the severity of his PTSD prior to May 27, 2014, thus warranting a 50 percent rating. In this regard, disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). As in the instant case, where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Pursuant to that General Rating Formula, a 30 percent rating is assigned when there is 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). A 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation...requires an ultimate factual conclusion as to the Veteran's level of impairment in most areas." Vazquez-Claudio, supra; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "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." 38 C.F.R. § 4.126(a). The Global Assessment of Functioning (GAF) reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994). The GAF score is based on all of the Veteran's psychiatric impairments. A GAF score between 51 and 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). The Board notes that VA recently updated references in its regulations to the Fifth Edition of the DSM (DSM-V). However, the changes do not apply to claims that were certified for appeal to the Board on or before August 4, 2014. See 80 Fed. Reg. 14, 308 (March 19, 2015) (Applicability Date). Inasmuch as the Veteran's appeal was originally certified to the Board in January 2014, the amendments are not applicable. The Veteran filed his current claim for service connection for PTSD in June 2010. He was afforded a VA examination in March 2011. Although the claims file was not available for review, the Veteran's VA treatment records were reviewed. The Veteran reported intrusive thoughts, flashbacks of an assault while in service, anxiety, some depression, sleep disturbance, hypervigilance, and waking up often at night. It was noted that he lived with his fiancée for the past three years. On examination, he was alert and oriented times three, but did complain of some anxiety. His last suicide attempt was in 2005, but he currently denied suicidal or homicidal ideation. There was no evidence of a thought disorder, hallucinations, or delusions. The Veteran complained of generalized anxiety and occasional panic attacks once or twice a month with a three to four out of 10 intensity level. Eye contact was good and sensorium was clear. There was no evidence of delirium, and the Veteran was sober. He socialized with his fiancée, but has some hypervigilance that was worse in crowds. The Veteran remembered two out of three words at three minutes and was able to spell the word "world" forward and backward without problem. The examiner observed that the Veteran met the stressor criteria due to an in-service assault. He had social dysfunction in that he was married and divorced once already and had a history of heavy drinking with multiple DUIs. He had some employment dysfunction over the years from a number of causes, including drinking and stress. However, he had been sober for almost three years and was gainfully employed as an Addiction Readjustment Counselor. Capacity for improvement and remission secondary to assault was still good. The Veteran was sober, went to Alcohol Anonymous on a regular basis, had gotten back on his feet being an Adjustment Counselor and had a supportive fiancée. The diagnoses were PTSD secondary to an assault in the military and alcohol dependence secondary to PTSD. His stressors were considered mild to moderate, and his GAF score was 60. VA treatment records during the relevant time period showed that the Veteran received regular treatment with a social worker. His relationship with his significant other was going well. It was noted that the Veteran worked as a substance abuse counselor part time as well as another part time job, while looking for a permanent position. He still reported symptoms such as easily angered/irritated, suspiciousness, isolation, and withdrawal. However, his appearance was neat and casual. He was alert and oriented. He consistently denied suicidal or homicidal ideations. September 2011, April 2012, and April 2013 clinical records specifically noted that although he continued to experience symptoms, the Veteran was doing well at this time. Another February 2012 record showed that the Veteran presented in an upbeat, talkative mood with congruent affect. At his January 2014 Board hearing, the Veteran reported symptoms of anger, frustration, anxiety, irritability, memory loss, lack of concentration, and lack of empathy for his clients. He also reported that he had nightmares two to three times per night, sleep impairment, suspiciousness, and hypervigilance. However, despite these symptoms, the Veteran indicated that he was able to work full time, as he had a supportive supervisor who he could speak with about his problems on almost daily basis, about four or five times a week. The Veteran indicated that his supervisor, who was also his former substance abuse counselor, would counsel him and help him control his emotions. While he also occasionally did have some anger issues, he had not had a violent episode since prior to 2010. The Veteran also reported having close relationships with friends and family. He expressly denied any suicidal or homicidal ideation. He also denied delusions and hallucinations. On remand, the Veteran was afforded another VA examination on May 27, 2014. The Veteran's electronic records were reviewed. The Veteran reported being divorced and having an 18-year-old son who he was planning to see for high school graduation. He was still living with his fiancée for the last five years. The relationship was stable and the longest relationship he ever had. The Veteran had a bachelor's degree in psychology and substance abuse counseling. He periodically went to AA. He was currently employed as a case manager for Volunteers for America. The Veteran reported overdosing in 2005. He was not currently receiving psychiatric treatment but had been seeing a social worker at VA. The Veteran reported a long history of DUIs, including losing his license, and alcohol related offenses. He reached sobriety in 2008 and had been sober for six years. The examiner found that the following criteria were met to establish the current PTSD diagnosis: exposure to traumatic event; recurrent distressing dreams; persistent avoidance of distressing memories and external reminders; persistent negative emotional state; marked alterations in arousal and reactivity including irritable behavior, hypervigilance and sleep disturbance; duration of more than one month; the symptoms caused clinically significant distress or impairment in social and occupational functioning; and was not attributable to physiological effects of a substance or another medical condition. The following symptoms were noted: anxiety, chronic sleep impairment, disturbances in motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. He also reported being fearful since the assault as well as intrusive thoughts and flashbacks. The Veteran was capable of managing his financial affairs. The Veteran also denied being suicidal or homicidal. The diagnosis was PTSD due to personal assault and alcohol dependence in remission due to PTSD. The examiner determined that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally satisfactorily with normal routine behavior, self-care and conversation. After reviewing the evidence of record, the Board finds that the preponderance of the evidence is against a finding that it was factually ascertainable that the Veteran's PTSD resulted in manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity prior to May 27, 2014. Although, arguably, the Veteran had disturbances of mood and motivation, which is a symptom under the 50 percent criteria, he did not exhibit symptoms such as flattened affect, circumstantial, circumlocutory, or stereotyped speech; more than once a week panic attacks; difficulty in understanding complex commands; impairment of short and long-term memory; impaired judgment; or impaired abstract thinking. The March 2011 examination noted occasional panic attacks once or twice a month, which is contemplated under the criteria for a 30 percent rating. Moreover, the Veteran was alert, oriented, and cleanly dressed, with no loosening of associations, delusional thinking, or loss of reality testing. VA treatment records showed that he was easily angered/irritated as well as exhibited suspiciousness, isolation, and withdrawal, which again are contemplated in the 30 percent criteria. Moreover, on a few occasions during the course of the appeal, it was observed that the Veteran was doing well. The Board recognizes that, prior to filing his claim, the Veteran reported a suicide attempt in 2005. However, throughout the course of the appeal, he has expressly denied any suicidal ideation. Thus, it appears that any contemplation of suicide that the Veteran had prior to filing his claim for service connection had been resolved and was not evident during the relevant time period. The Board notes that the Court in Mauerhan v. Principi, 16 Vet. App. 436 (2002), stated that the symptoms listed in VA's general rating formula for mental disorders is noted intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. However, the Court further indicated that without those examples differentiating a 30 percent evaluation for a 50 percent evaluation would be extremely ambiguous. Id. at 442. In light of the Mauerhan case, the Board observes that the Veteran has been in a long-term relationship with his fiancée, thus exhibiting his ability to maintain long-term social relationships. The March 2011 VA examiner also observed that he was gainfully employed. The Veteran was able to perform his activities of daily living during this period. Furthermore, at his January 2014 Board hearing, the Veteran testified that he worked full time and had close relationships with friends and family. In other words, the overall PTSD symptomatology during this period did not cause occupational and social impairment with reduced reliability and productivity. Therefore, the Board must conclude that the Veteran's impairment during this time period warranted no more than a 30 percent rating for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Board also finds it significant that the May 2014 VA examiner found that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation, which again is the criteria for a 30 percent rating. The demonstrated PTSD symptomatology did not more nearly approximate the criteria for a higher rating. In sum, the clinical evidence simply does not show that a higher rating is warranted prior to May 27, 2014. With regard to the February 2017 Memorandum Decision, the Board observes that the Court did not find any error in the September 2015 decision in regard to the Board's determination of the Veteran's level of social functioning. In fact, the Court only found error insofar as the Board did not provide an adequate statement of reasons or bases regarding the effect the Veteran's PTSD had on his occupational functioning. Specifically, the Court found that the Board relied on evidence that the Veteran worked full time to deny a higher rating, but failed to address the nature of his employment. In Carter v. Shinseki, 26 Vet. App. 534, 542-43 (2014) (vacated on other grounds sub nom. Carter v. McDonald, 794 F.3d 1342 (Fed. Cir. 2015)), the Court essentially ruled that when an attorney argues specific issues before the Court and raises no additional issues on remand, the Board is required to "focus on the arguments specifically advanced by the attorney...see Forcier [v. Nicholson, 19 Vet. App. 414,] 426 [(2006)], and those terms will serve as a factor for consideration as to whether or to what extent other issues raised by the record need to be addressed." In this regard, while the Board acknowledges that the Veteran testified that his supervisor needed to counsel him on a daily basis to resolve his anger and irritability towards clients, the Board finds that, despite such symptoms and counseling, his PTSD symptoms were not of a frequency, severity, or duration so as to result in occupational impairment with reduced reliability and productivity. Specifically, while the Veteran has reported needing additional counseling on the job, there is no indication that such impacted his ability to fully execute his job duties. Further, while he reported that he was not empathetic towards his clients and would be short with them, such symptoms, and their resulting impairment, are considered in his currently assigned 30 percent rating, which contemplates occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Furthermore, he has not indicated, nor does the record show, that he has received any disciplinary action due to attendance issues or misconduct at work. Rather, the Veteran has consistently manifested an ability to maintain an effective work relationship with his supervisor such that he has been entrusted by his supervisor to work with and treat vulnerable populations. Therefore, while the Veteran's PTSD does result in occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, which is consistent with his currently assigned 30 percent rating, the Board finds that the frequency, severity, and duration of his symptomatology does not result in occupational impairment with reduced reliability and productivity, even in consideration of the fact that he requires almost daily counseling from his supervisor. The Board recognizes that the Veteran's GAF score of 60 assigned at the March 2011 VA examination is indicative of moderate symptoms that contemplate certain symptoms listed under the criteria for a 50 percent rating. Nevertheless, the Board notes that a GAF score reflects merely an examiner's opinion of functioning levels and in essence represents an examiner's characterization of the level of disability that by regulation is not, alone, determinative of the appropriate disability rating. See Richard v. Brown, 9 Vet. App. 266, 267 (1996). It is noted that a disability rating depends on evaluation of all the evidence, and an examiner's classification of the level of a psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage disability rating to be assigned. 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (1995). In the instant case, despite the GAF score assigned the demonstrated symptomatology does not persuasively show that the regulatory criteria for a 50 percent rating have been met. Given the frequency, severity, and duration of those symptoms, as reflected in the medical evidence, the Board finds that they result in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. They do not more closely, approximate the types of symptoms contemplated by a 50 percent rating, and therefore, a 50 percent rating is not warranted prior to May 27, 2014. See Vazquez-Claudio, 713 F.3d at 114 (holding that a Veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). The Board has carefully reviewed and considered the Veteran's statements and hearing testimony regarding the severity of his PTSD. The Board acknowledges that the Veteran, in advancing his appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). However, in the instant case, the Board finds that the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. In this regard, the symptoms described at the Board hearing, including anxiety, suspiciousness, panic attacks, mild memory loss, and chronic sleep impairment are all contemplated in the current 30 percent rating. Importantly, although again arguably there have been disturbances of motivation and mood, the Veteran did not indicate that he suffered from flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; or difficulty in establishing and maintaining effective work and social relationships. In this regard, although he was not very trusting of strangers, he specifically testified that he had close relationships with friends and family. In sum, the lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has also considered whether additional staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that his symptomatology has been adequately rated throughout the appeal period. Therefore, assigning further staged ratings for such disability is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In conclusion, the Board finds no basis upon which to award an effective date prior to May 27, 2014, for the assignment of an initial 50 percent rating for PTSD. In making this determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the assignment of a higher 50 percent rating prior to such date. Therefore, the benefit of the doubt doctrine is not applicable in the instant appeal, and the Veteran's claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER An effective date prior to May 27, 2014 for the assignment of an initial 50 percent rating for PTSD is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs