Citation Nr: 1753485 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 07-27 542 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD), prior to October 7, 2009. 2. Entitlement to total disability rating based on individual unemployability (TDIU) due to PTSD, prior to October 7, 2009. 3. Entitlement to special monthly compensation (SMC) at the housebound rate, prior to October 7, 2009. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney-at-Law WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J.N. Moats, Counsel INTRODUCTION The Veteran had active service with the United States Army from March 1971 to April 1972, to include a tour of duty in Vietnam. He is in receipt of a Combat Infantryman Badge (CIB). This matter comes to 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 Waco, Texas, which granted service connection for PTSD, with a 30 percent evaluation, effective from July 26, 2006. The Veteran and his wife presented testimony at a personal hearing before the undersigned Acting Veterans Law Judge in June 2010. A transcript is of record. In September 2010, the Board remanded the claim for an initial rating in excess of 30 percent for PTSD for additional development. In a decision dated October 2012, the Board denied the Veteran's claim of entitlement to an initial disability rating in excess of 30 percent prior to October 7, 2009 for PTSD, granted a 50 percent rating from October 7, 2009, and denied a disability rating in excess of 50 percent from October 7, 2009. The Veteran appealed the Board's decision as to his PTSD claim to the United States Court of Appeals for Veterans Claims (Court). In January 2013, the parties to the appeal filed a Joint Motion for Remand (JMR). The Court granted the motion, vacated the Board's decision, and remanded the matter for further proceedings. The Board issued an August 2013 decision denying entitlement to an initial disability rating in excess of 30 percent, and in excess of 50 percent from October 7, 2009. The Veteran again appealed the Board's decision to the Court, resulting in a December 2014 Memorandum Decision vacating the Board's decision and remanding the issue back to the Board. Specifically, the Court instructed the Board to address an October 27, 2009 Social Security Administration Function Report in which the Veteran reported a history of aggressive behavior. Subsequently, in November 2015, the Board awarded a 50 percent disability rating prior to October 7, 2009 and a 70 percent disability rating thereafter. The Veteran appealed to the Court the portion of the Board's decision that awarded a 50 percent disability, but no higher, prior to October 7, 2009. In a March 2017 Memorandum Decision, the Court vacated and remanded this part of the Board's decision finding that the Board failed to adequately explain its determination that the Veteran was entitled to no more than a 50 percent disability rating during this period. In a September 2017 statement, the Veteran, through his representative also asserted that a TDIU was warranted prior to October 7, 2009 as the Veteran's PTSD had rendered him unable to secure and follow substantially gainful employment since he last worked in June 2009. The Court has held that entitlement to TDIU is part and parcel of an increased rating claim where employability is put at issue. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Further, the issue of entitlement to SMC is part and parcel of a claim for increased compensation and does not require submission of a separate claim. See Akles v. Derwinski, 1 Vet. App. 118 (1991). As such, these matters are also in appellate status as listed on the front page of this decision. In September 2017, the Veteran's representative also submitted additional evidence along with waiver of RO consideration of this evidence. As such, this evidence may be properly considered by the Board. FINDINGS OF FACT 1. Since the date of award of service connection, July 26, 2006, the Veteran's service-connected PTSD has caused occupational and social impairment with deficiencies in most areas due to such symptoms as impaired memory, impaired concentration, hypervigilance, exaggerated startle response, emotional numbness, sleep disturbance, panic attacks, impaired impulse control and difficulty in adapting to stressful circumstances, without more severe manifestations that more nearly approximate total occupational and social impairment. 2. Since June 12, 2009, the last date of employment, the Veteran's service-connected PTSD has rendered him unable to secure and follow a substantially gainful occupation. 3. From June 12, 2009, the Veteran has a total disability evaluation due solely to his service-connected PTSD, and additional service-connected disabilities of epidermal cyst of the right and left cheeks and upper and mid-bac, rated as 60 percent disabling. CONCLUSIONS OF LAW 1. Effective July 26, 2006, the criteria for a 70 percent rating, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2017). 2. Effective June 12, 2009, the criteria for TDIU due to service-connected PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 4.16 (2017). 3. From June 12, 2009, the criteria for entitlement to special monthly compensation at the housebound rate, on a statutory basis, have been met. 38 U.S.C. § 1114(s) (2012); 38 C.F.R. § 3.350 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist With respect to the Veteran's claims herein, the Veteran has not alleged that VA has not fulfilled its duty notify or assist in the development of his claims. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Initial Higher Rating for PTSD The Veteran is seeking an initial higher rating for his PTSD prior to October 7, 2009. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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). Where, as in the instant case, 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). As in the instant case, 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 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. The next-higher evaluation of 70 percent 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. Id. A 100 percent evaluation 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. Id. As the United States Court of Appeals for the Federal Circuit has held, 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, 116-17 (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, 713 F.3d at 117-18 ; 38 C.F.R. § 4.130, Diagnostic Code 9411. Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's 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. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising 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(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. The Global Assessment of Functioning (GAF) Scale 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 Scale score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job); and 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 the newer Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5) has been released, and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. However, since much of the relevant evidence was obtained during the time period that the DSM-IV was in effect, and the DSM-5 is not applicable to claims certified to the Board before August 14, 2014, as in the instant case, the Board will still consider this information as relevant to this appeal. The Veteran filed his claim for service connection or PTSD in July 2006. In relevant part, a May 2006 treatment note indicates that the Veteran was referred by his primary care physician. The Veteran reported being seen approximately 30 years prior at the Dallas VA Medical Center (VAMC) for depression. The Veteran reported asking his primary care physician for Zoloft 15 years prior, and later took Xanax as needed. The Veteran asserted difficulty adjusting after Vietnam, and that he went through jobs "like other people go through socks." The Veteran denied ever being suicidal, but did experience sleep impairment, intrusive thoughts daily, avoidance of stimuli reminding him of Vietnam. He denied flashback and hypervigilance. He reported feeling "emotionally blunted," and that his PTSD symptoms affected his career and have resulted in not having many friends. However, he did state that his marriage was unaffected. The Veteran reported decreased energy, decreased concentration, decreased interest in things that usually bring him pleasure, and sitting around a lot watching TV. He reported wishing he had acted differently as a parent. There was no change in appetite. He felt slowed from both a psychological and physical stand point. He reported decreased motivation, increased irritability, and past rage episodes, but none now. He denied actual panic attacks, except when first returning from Vietnam. He denied any history of violence or assaulting others. The Veteran reported that his marriage was stable and that his relationship with his two sons was good. He has a few friends and attends church on a regular basis. The Veteran reported being able to maintain long-term jobs recently. At the time, he was employed as a maintenance worker, a position he held for the previous three years. Upon examination, the Veteran was well groomed, appropriately dressed, cooperative with good eye contact, and easily engaged in conversation. The examiner noted no psychomotor abnormalities and no abnormal movements. Speech was normal. Mood was depressed, affect blunted. Thought process was normal, and thought content was negative for perceptual disturbances, delusional material, suicidal or homicidal ideation. The Veteran was alert and oriented in all spheres. Concentration and memory were intact. A GAF score of 55 was reported. A September 2006 mental health outpatient treatment plan note reports the Veteran as married and working in maintenance from 6am to 2:30pm, after which he would watch television from 3:30pm to 9:30pm. He indicated that he had been distant with his older brother up to the present and that his younger brother and both parents were deceased. Depressive symptoms and trauma history and related anxiety symptoms were noted to be active foci of mental health treatment. The Veteran reported trauma-related memories or nightmares and flashbacks or dissociative episodes a few times per week. At a December 2006 VA psychiatric examination, the Veteran reported that he had been married for 34 years to his only wife, had a GED, and was working in a factory where he had been doing maintenance for the past three and one-half years. The Veteran reported receiving mental health treatment for the past two to three years through VA and that he was taking medications to help with sleep disturbance and to improve his mood. His current symptoms included depression; feeling useless, but not suicidal; middle insomnia; an inability to finish projects; difficulty concentrating; persistent thoughts of Vietnam; and flashbacks. He denied nightmares, but reported that his wife indicated that he had a history of nightmares, and also denied and any problems with alcohol or drugs. The Veteran reported that his depression kept him from doing a good job at work and that he had been separated three to four times from his wife, but that his marriage was okay at the present time. He indicated that he was able to engage in a normal range and variety of activities of daily living without interruption of his typical daily routine and that his leisure activities included going to church. Mental status examination revealed that the Veteran was somber and lethargic throughout the course of the examination. Thought processes were logical, coherent and relevant. The Veteran was described as an attractive, articulate, verbal, well-dressed and well-groomed individual who was overall mentally intact and cooperative. He was somewhat overweight, but seemed intelligent and his speech was well understood. The Veteran was oriented to time, place, person and situation; affect was flat and blunted; and reasoning, fund of general information, verbal comprehension, and concentration were all described as good. The Veteran did not exhibit any psychomotor slowing or agitation, but he reported that his short-term memory was poor and that sensorium was cloudy. He denied having any head trauma, seizures or stroke. A review of psychological symptoms resulted in the endorsement of anxiety, panic attacks, depression, insomnia, and appetite disturbance. The Veteran reported that he kept to himself and the examiner noted that he acted very depressed during the course of the psychological interview. The examiner reported that the Veteran's problem behaviors have to do mainly with his depression and his overall despondency. The Veteran indicated that he had never been suicidal, but felt quite useless. He also had problems concentrating. It was the examiner's opinion that the Veteran was indeed depressed, had some obsessive tendencies, and may have problems concentrating because of the severity of his depression. Axis I diagnoses of PTSD with a GAF score of 65; major depressive disorder with a GAF score of 60; and undifferentiated somatoform disorder with a GAF score of 65, were assigned. The Veteran's overall GAF score was 65. The examiner reported that the Veteran's depression was partially related to his PTSD, but his somatoform disorder was not related to either condition. The examiner also noted that the Veteran complained of a great deal of distress, stated that he felt useless, had a number of neurotic tendencies and engages in self-defeating behavior. The examiner again noted that the depression was only partially related to PTSD and that such individuals (according to the MMPI) tend to be immature, egocentric and demanding, and that they channel unacceptable drives and urges into physical complaints. The examiner noted that the Veteran may actually be much better off than he realizes because he had had a steady job for many years and appeared to have a relatively stable marriage. A February 2007 mental health attending note reveals that the Veteran was seen for 30 minutes and reported compliance with his medication regimen. Medication had been helpful with his mood, which was rated at 4/5. Energy was low, the Veteran was sleeping 6-7 hours per night and his appetite was good. Interest had improved but was still low and the Veteran denied suicidal thoughts and any history of attempts. He also denied homicidal ideation and psychotic symptoms. He noted intrusive thoughts/memories on a daily basis, occasional nightmares, some avoidance behaviors, panic attacks every 1-2 months, and anxiety at a level 8/10. Mental status examination revealed constricted affect, low/slow speech, decreased psychomotor activity, and goal-directed thoughts. A GAF score of 55 was assigned. A November 2007 mental health attending note reveals that the Veteran was seen for 30 minutes, at which time he reported that he had run out of medication about a month ago and had noticed much increased depression and irritability. Mood was rated at 2/5, energy and interest were low, the Veteran was sleeping 4-5 hours per night with multiple awakenings, and appetite was somewhat low. The Veteran denied suicidal thoughts and any history of attempts and homicidal ideation. There were no psychotic symptoms. He noted intrusive thoughts/memories on a daily basis, occasional nightmares, some avoidance behaviors, panic attacks every 1-2 months, anxiety at a level 8/10, and increased irritability and worsened concentration, both of which had significantly impaired occupational stability. Mental status examination revealed constricted affect, low/slow speech, decreased psychomotor activity, and goal-directed thoughts. A GAF score of 55 was assigned. The Veteran was seen for a 30 minute medication management appointment in March 2008, the first time he was being seen at that clinic. He reported that his mood had been better and said his anxiety was better since a medication had been added, though he still had times when he felt anxious/depressed. The Veteran endorsed depressive ruminations, guilt feelings, recurrent intrusive thoughts about his trauma, but said he had not had nightmares for several months and had not had any recent panic attacks, the last one occurring two months prior. He denied suicidal and homicidal ideation, alcohol and drug abuse, and psychotic symptoms. The Veteran indicated that he slept about 4-5 hours per night mostly a function of needing to get up at 4am and not going to bed until late. He endorsed initial insomnia. His appetite was fair and taste for food was partially intact.. In October 2008, the Veteran reported that he had run out of two medications the week prior and had noticed that he had been more irritable and was sleeping poorly. He was still feeling depressed with one of the medications and had poor energy and concentration. The Veteran also noted that he still felt hopeless at times. He was sleeping 4-5 hours per night and had no thoughts of suicide. Mental status examination revealed that he was clean, neatly dressed and well groomed. Behavior was cooperative and pleasant and he made good eye contact. Psychomotor activity was neither increased nor decreased. Speech was spontaneous, clear, and with appropriate volume and rate. Mood was depressed, affect was blunted, concentration was at an appropriate level, recent and remote memory were intact, and the Veteran was alert and oriented times four. Thought content was coherent, logical and goal oriented. There were no delusional or paranoid thoughts, no suicidal or homicidal ideation or intent, and no evidence of any auditory or visual hallucinations. Thought process was linear and insight and judgment were fair. A GAF score of 50 was assigned. The Veteran was seen for 30 minutes in January 2009, at which time he reported that he had been married since 1972 and was currently living with his wife and working in maintenance. He noted that he was having trouble at work due to irritability and was concerned that this could cost him his job. Mood was rated 2/5, energy was low, the Veteran was sleeping 5-6 hours per night, appetite was somewhat low and interest was low. The Veteran denied suicidal thoughts and a history of attempts but indicated that he felt worthless, sometimes hopeless. He denied homicidal ideation and psychotic symptoms. He reported intrusive thoughts/memories daily, occasional nightmares, anxiety at a level 8-9/10, some avoidance behaviors, panic attacks on a weekly basis, increased irritability and worsened concentration, both of which were significantly impairing his occupational stability. Mental status examination revealed constricted affect, low/slow speech, decreased psychomotor activity, and goal-directed thought processes. A GAF score of 55 was assigned. A May 2009 mental health attending note reveals that the Veteran reported continuing to feel depressed and irritable, was losing his temper easily at work, was feeling hopeless at times, and had poor energy. He was sleeping 6-7 hours per night and had occasional nightmares. Anxiety was well-controlled and he denied thoughts of suicide. Mental status examination revealed that he was clean, neatly dressed, and well groomed. Behavior was cooperative and pleasant. Eye contact was good and psychomotor activity was neither increased nor decreased. Speech was spontaneous and clear with appropriate volume and rate. Mood was depressed, affect was blunted, concentration was at an appropriate level, recent and remote memory were intact, thought content was coherent, logical and goal-oriented, and the Veteran was alert and oriented times four. There were no delusional or paranoid thoughts, no suicidal or homicidal ideation/intent, and no evidence of any auditory or visual hallucinations. Thought process was linear and insight and judgment were fair. Axis I diagnoses of PTSD and depressive disorder, not otherwise specified (NOS), were made and a GAF score of 50 was assigned. A July 2009 mental health assessment note reveals that the Veteran rated his depression at 3/10, which was an improvement due to medication increase, and indicated that he had no irritability, though his affect was apathetic, blunt and not reactive. Psychomotor retardation was positive, the Veteran was still bothered by thoughts of what happened in service and had remembered the incident three times since May 2009. He was sleeping 6-7 hours per night and had been laid off from his job, though he still had vacation time to cover and was going to look for another job. The Veteran denied irritability and indicated that anxiety was well-controlled. He denied suicidal or homicidal ideation. He was not psychotic or manic. Mental status examination revealed that he was alert, dysthymic, cooperative and pleasant. Speech was fluent, spontaneous and not pressured, the Veteran was well groomed and made good eye contact, and his affect was blunt without expression. The Veteran denied any aggressive behavior and thoughts of self-harm or harm to others. He also denied any auditory or visual hallucinations and delusions and psychotic symptoms. Thought content was coherent, logical, and goal-oriented and there were no delusional or paranoid thoughts. Thought process was linear and insight and judgment were fair. The Veteran was seen for 30 minutes in August 2009, at which time he reported being on short-term disability from work, with significant financial problems. Mood was rated 3/5, energy was low, the Veteran was sleeping 5-7 hours per night with occasional awakenings, and appetite and interest were low. He denied suicidal thoughts and a history of attempts and denied homicidal ideation. The Veteran noted daily intrusive thoughts/memories, occasional nightmares, anxiety at 8/10, some avoidance behaviors, and occasional panic attacks. Mental status examination revealed that the Veteran was appropriately groomed with constricted affect, low/slow speech, decreased psychomotor activity, and goal-directed thought processes. A GAF score of 55 was assigned. A Social Security psychiatric assessment dated in September 2009 noted that the Veteran had a medically determinable impairment present that does not precisely satisfy diagnostic criteria, but was noted to be depressive disorder NOS and PTSD. In terms of functional limitation, there was no restriction of activities of daily living or episodes of decompensation, each of extended duration; mild difficulties in maintaining social functioning; and moderate difficulties in maintaining concentration, persistence or pace. The findings from VA treatment records dated in January 2007, May 2009, and July 2009 were reported. The summary conclusions were as follows: the ability to remember locations and work-like procedures, the ability to understand and remember very short and simple instructions, the ability to carry out very short and simple instructions, the ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances, the ability to sustain an ordinary routine without special supervision, the ability to work in coordination with or proximity to others without being distracted by them, the ability to make simple work-related decisions, the ability to interact appropriately with the general public, the ability to ask simple questions or request assistance, the ability to accept instructions and respond appropriately to criticism from supervisors, the ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness, the ability to be aware of normal hazards and take appropriate precautions, the ability to travel in unfamiliar places or use public transportation, and the ability to set realistic goals or make plans independently of others were not significantly limited. The following were moderately limited: the ability to understand and remember detailed instructions, the ability to carry out detailed instructions, the ability to maintain attention and concentration for extended periods, the ability to complete a normal work day and worksheet without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods, the ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes, and the ability to respond appropriately to changes in the work setting. In June 2010, the Veteran submitted an application for a TDIU indicating that he lasted worked on June 12, 2009 and that his PTSD had prevented him from securing or following substantially gainful employment since that date. . Moreover, significantly, at the Board hearing, the Veteran testified that he had been involved in physical confrontations at work as well as verbal confrontations with his wife, colleagues and members of church. His wife also testified that he was verbally abusive towards her. She further stated that the Veteran suffered from impaired memory. Importantly, a May 2013 private vocational assessment documents the Veteran's history of low energy, difficulty concentrating, sleep disturbance, anxiety, irritability, depression, disorientation, flashbacks, nightmares, panic attacks, and occupational impairment. The report also noted the Veteran's work history, including three years manufacturing of aluminum; over seven years operating heavy construction equipment and driving dump trucks; two years working construction installing underground cables; for nine years he performed general maintenance at a prison; and his last job was performing maintenance on production machines. The examiner opined that it is at least as likely as not that the Veteran's PTSD prevented him from securing and following a substantially gainful occupation since at least June 2009 when he stopped working and reasonably as far back as 2006. In applying the rating criteria to the evidence of record, the Board finds the Veteran's PTSD more nearly approximates the criteria for a 70 percent evaluation from July 26, 2006, the date of award of service connection. Based on the Veteran's symptoms discussed above, the evidence of record demonstrates that the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas from that date. The evidence during the period in question documents that the Veteran experienced impaired memory, impaired concentration, hypervigilance, exaggerated startle response, emotional numbness, sleep disturbance, panic attacks, impaired impulse control (such as unprovoked irritability with periods of violence), and difficulty in adapting to stressful circumstances (including work or a work-like setting). Although the Veteran has been married for many years, there is documentation of marital problems due to the Veteran's irritability, including periods of separation and verbal abuse towards his wife. Moreover, it was noted that he was isolated with very few friends as well as documentation of verbal and physical confrontations with coworkers and members of his church. In sum, the evidence showed that the Veteran had an inability to establish and maintain effective relationships that has existed since the date of award of service connection. Additionally, the November 2007 clinical record indicated that the Veteran had increased irritability and worsened concentration, both of which had significantly impaired occupational stability. Importantly, the May 2013 private vocational assessment found significant occupational impairment since 2006 further showing a difficulty in adapting to stressful circumstances (including work or a work like setting). In sum, the evidence documents occupational and social impairment with deficiencies in work, mood, and family relations. Significantly, although his GAF scores were higher at times, during this period, the Veteran had been assigned a GAF score of 50, which is indicative of serious symptoms such as suicidal ideation or obsessional rituals. In summary, resolving all benefit of the doubt in favor of the Veteran, a 70 percent rating is warranted from July 26, 2006. See Fenderson. However, the preponderance of the evidence is against a higher evaluation of 100 percent during this period. In this regard, the Veteran has been consistently alert and fully oriented; his thought processes and communications were not grossly impaired; and his speech was clear and logical. The medical evidence of record clearly showed that the Veteran did not have persistent delusions or hallucinations, or grossly inappropriate behavior. Further, there is no medical evidence of a persistent danger to hurting self or others. The Veteran has consistently denied suicidal or homicidal ideation. Moreover, although there were some reports of memory problems, there has been no medical finding that the Veteran's memory loss was to such an extent that he consistently did not remember names of close relatives, his own occupation or his own name. Although documentation of some marital issues, he has still been able to maintain a relationship with his current wife. Moreover, again, the Veteran's GAF scores are indicative of moderate or serious symptoms such as suicidal ideation or obsessional rituals, which are criteria under the current 70 percent rating. In other words, the lowest GAF score assigned by medical professionals when treating the Veteran reflected the 70 percent rating criteria. The record does not support a finding that the Veteran's PTSD has caused total occupational and social impairment. In sum, the degree of PTSD impairment is adequately contemplated by the current 70 percent rating. There is simply no showing of total occupational and social impairment so as to warrant the next-higher 100 percent evaluation. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his PTSD. The Board acknowledges that the Veteran, in advancing this 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). In this case, however, 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. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Moreover, the Board has contemplated the Veteran's statements concerning the severity of his symptoms when assigning the current 70 percent disability rating, effective July 26, 2006. The Board has considered whether staged ratings are appropriate for the Veteran's service-connected PTSD. See Fenderson, supra. However, the Board find that his symptomatology has been stable since the award of service connection; therefore, assigning staged ratings for such disability is not warranted. In conclusion, an initial 70 percent rating, but no higher, is warranted for the Veteran's service-connected PTSD, effective July 26, 2006. In denying a higher rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. III. TDIU The Veteran has asserted that his service-connected PTSD renders him unemployable. In order to establish service connection for TDIU, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. VA regulations establish objective and subjective standards for an award of a total rating based on unemployability. When the Veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned where one disability is ratable at 60 percent or more, or where there are two or more disabilities, at least one disability is ratable at 40 percent or more, and any additional disabilities result in a combined rating of 70 percent or more, and the disabled person is unable to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(a). A total disability rating may also be assigned on an extra-schedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). The Board has herein awarded a 70 percent disability rating for the Veteran's PTSD, effective July 26, 2006. As such, he meets the schedular criteria for TDIU under 38 C.F.R. § 4.16(a) as of that date. Moreover, the evidence of record shows that the Veteran last worked on June 12, 2009. However, the Board must still determine whether the Veteran's service-connected PTSD results in impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. In this regard, the record includes a May 2013 vocational assessment where the examiner clearly opined that it is at least as likely as not that the Veteran's service-connected PTSD has prevented him from securing and following a substantially gainful occupation since at least since June 2009 when he stopped working; and reasonably as far back as 2006. Moreover, importantly, SSA records showed that the Veteran has been considered disabled since June 16, 2009 due to his psychiatric disorder. Further, the Veteran and his wife have consistently reported that he has not been able to work due to his PTSD since his last job. Thus, when considering the totality of the functional impairment caused by his service-connected PTSD as described by the lay and medical evidence of record, as well as taking into consideration his work history, education and experience, and when resolving all doubt in his favor, it would seem that the Veteran would be precluded from substantially gainful employment due to his PTSD. In conclusion, when resolving all benefit of the doubt in the Veteran's favor, the Board must conclude that the Veteran is unemployable due to his service-connected PTSD and, in turn, entitlement to TDIU is warranted. Again, the record shows that the Veteran reported that he last worked on June 12, 2009. As such, the appropriate effective date for TDIU is the day after he was last employed, i.e., June 12, 2009. 38 U.S.C.A. § 5107(b). IV. Special Monthly Compensation Special Monthly Compensation is payable for housebound status on a statutory basis where the claimant has a single service-connected disorder rated as totally disabling and one or more distinct service-connected disabilities, which are independently ratable at 60 percent and involve different anatomical segments or bodily systems. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). Alternatively, such compensation may be granted when the claimant is permanently housebound by reason of service-connected disability or disabilities. Id. As discussed above, the Board has granted entitlement to TDIU based solely on PTSD from June 12, 2009. Further, the Veteran has additional service-connected disabilities of epidermal cyst, residual scar upper back 3/4 inch (claimed as skin cysts and chloracne), epidermal cyst, right cheek 1/4 inch, with disfigurement (claimed as skin cysts and chloracne), epidermal cyst, left chest 1/2 inch (claimed as skin cysts and chloracne), epidermal cyst, residual scar mid back vertical 1-1/2 inch (claimed as skin cysts and chloracne), epidermal cyst, residual scar mid back 2 inch (claimed as skin cysts and chloracne), epidermal cyst, right cheek 1/4 inch, tender (claimed as skin cysts and chloracne), epidermal cyst, residual scar mid back 1-1/2 inch (claimed as skin cysts and chloracne), epidermal cyst, residual scar upper back 1/2 inch (claimed as skin cysts and chloracne), independently ratable at 60 percent or more. Thus, from June 12, 2009, the schedular criteria for entitlement to SMC due to housebound status on a statutory basis have been met. The Board notes that the issue of entitlement to SMC for aid and attendance has not been raised by the record and is not before the Board at this time, as the evidence of record does not indicate that the Veteran is rendered so helpless due to his service-connected disabilities so as to require regular aid and attendance of another person during this period. See Akles v. Derwinski, 1 Vet. App. 118 (1991) (the issue of entitlement to SMC is part and parcel of a claim for increased compensation and does not require submission of a separate claim). In sum, SMC based on housebound status on a statutory basis is warranted from June 12, 2009. ORDER From July 26, 2006, a rating in excess of 70 percent, but no higher, for PTSD is granted, subject to the laws and regulations governing payment of monetary benefits. From June 12, 2009, TDIU is granted, subject to the laws and regulations governing payment of monetary benefits. From June 12, 2009, special monthly compensation at the housebound rate is granted, subject to the law and regulations governing the payment of VA compensation benefits. ____________________________________________ WILLIAM H. DONNELLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs