Citation Nr: 1756744 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 14-01 731 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a bilateral knee disability. 3. Entitlement to service connection for posttraumatic stress disorder (PTSD). 4. Entitlement to a rating in excess of 20 percent for depressive disorder for the period prior to May 25, 2016, and to a rating in excess of 30 percent thereafter. 5. Entitlement to special monthly compensation (SMC) at the housebound rate. 6. Entitlement to SMC based on the need for regular aid and attendance (A&A). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J.L. Ivey, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from July 1966 to July 1968, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated November 2010 and December 2012 by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. The Board remanded the appeal in a May 2016. The Board has bifurcated the SMC claim as reflected on the title page, given the favorable disposition on SMC at the housebound rate. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. The preponderance of the evidence reflects no current diagnosis of PTSD. 2. The preponderance of the evidence reflects the Veteran's currently diagnosed low back disability did not have onset in service and is not otherwise etiologically related to service. 3. The preponderance of the evidence reflects the Veteran's current bilateral knee arthritis is due to the natural aging process. 4. From November 8, 2011, the Veteran's depressive disorder has been manifested by occupational and social impairment with reduced reliability and productivity. 5. The Veteran is service connected for prostate cancer at 100 percent, with additional service-connected disabilities independently ratable at 60 percent. 6. The Veteran is not permanently bedridden and is not otherwise so helpless as to be in need of regular aid and attendance of another person. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 1154(a), 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2016). 2. The criteria for service connection for a low back disability are not met. 38 U.S.C. §§ 1110, 1112, 1154(a), 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2016). 3. The criteria for service connection for a bilateral knee disability are not met. 38 U.S.C. §§ 1110, 1112, 1154(a), 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2016). 4. The criteria for a rating of 50 percent, but no greater, for depressive disorder are met from November 8, 2011. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9434 (2016). 5. The criteria for SMC at the housebound rate are met. 38 U.S.C. § 1114(s) (2012); 38 C.F.R. § 3.350 (2016). 6. The criteria for entitlement to SMC based on the need for regular aid and attendance are not met. 38 U.S.C. §§ 1114(1), 5107(b) (2012); 38 C.F.R. §§ 3.350, 3.352(a) (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Principles of Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table decision). Facts and Analysis - PTSD The Veteran asserts that he has PTSD due to events that occurred during active duty, to include witnessing mortar attacks. As he is already service-connected for depressive disorder, which is evaluated under the same rating criteria, only the issue of entitlement to service connection for PTSD specifically, is before the Board. The first requirement for service connection is a current diagnosis. The first evidence of psychiatric treatment of record is a July 1976 VA examination report, which reflects that the Veteran was diagnosed with posttraumatic anxiety neurosis with some schizophrenic manifestations. The traumatic event underlying this diagnosis occurred after service, in March 1974, while performing duties related to his position with the state police. VA PTSD examinations dated November 2010 and May 2016 reflect the Veteran did not meet the criteria for a PTSD diagnosis using the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is required to establish service connection. Numerous VA psychiatric treatment notes reflect the Veteran has diagnoses of depressive disorder and substance abuse disorder and that he reported a history of PTSD; however, none of these treatment notes reflect that these providers actually diagnosed PTSD under the DSM criteria. Moreover, numerous VA treatment notes reflect that PTSD screening questionnaires were administered on a recurring basis and these screening tests are negative. The only medical evidence of record that suggests a PTSD diagnosis is the November 2009 letter from Dr. N.O.V., in which she indicates the Veteran reported sleep problems, nightmares and flashbacks of active duty-related traumatic incidents, hypervigilance, and other psychiatric symptoms. She requests in the letter that the Veteran be evaluated carefully for PTSD and she opines that he meets the criteria for PTSD under DSM criteria. The Board observes that the DSM criteria for a PTSD diagnosis are quite numerous and specific. The letter from Dr. N.O.V. does not reflect the complexities of the DSM criteria or indicate how the Veteran meets each element necessary for a diagnosis. Moreover, Dr. N.O.V. is a general practice doctor and she did not regularly treat the Veteran for his mental health problems. In support of this conclusion, the Board notes the Veteran's December 2014 response indicating that he did not receive treatment from Dr. N.O.V.; she evaluated him and reviewed his records twice and the resultant reports were forwarded to the RO. The Board acknowledges the Veteran's assertions that he has PTSD; however, the record does not show that he has the requisite training and expertise to self-diagnose such a complex disorder. In sum, the Board finds that the preponderance of the evidence does not show a current diagnosis of PTSD. The only evidence of record suggesting such a diagnosis is the November 2009 letter from Dr. N.O.V. As noted above, the Board is responsible for weighing the evidence of record. In the present case, the Board finds that the most probative evidence is against a finding of a PTSD diagnosis. In support of this conclusion, the Board relies on numerous VA mental health treatment notes as well as VA examination reports. The Veteran has been in receipt of regular mental health treatment at VA facilities during much of the appeal period, with providers that are specialists in mental health treatment. These providers have not assigned the Veteran a PTSD diagnosis. Moreover, two VA examination reports discuss the numerous and specific criteria for a PTSD diagnosis and indicate that the Veteran does not meet the criteria. The Board observes that VA psychiatric examinations must be conducted by: board-certified or board-eligible psychiatrists; licensed doctorate-level psychologists, or certain specified mental health professionals, under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist. M21-1, Part III, Subpart iv, 3.D.2.h. The November 2010 and May 2016 VA PTSD examiners included a VA doctorate level psychologist and a board certified psychiatrist. As such, their opinions are afforded more probative value that the brief letter from Dr. N.O.V. As the most probative evidence of record does not establish a current PTSD diagnosis; service connection is not warranted. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Facts and Analysis - Low Back Disability The Veteran asserts that his currently diagnosed lower back disability is related to service. He has current diagnosis of a back disability and he sought treatment for low back troubles several times during service, meeting the first two elements of service connection. The remaining element to be established is nexus. The Veteran's July 1966 Report of Medical Examination at entry reflects no abnormalities; his contemporaneous Report of Medical History reflects that he reported current and/or history of: swollen or painful joints but denied any back trouble. Service treatment records (STRs) reflect the Veteran sought treatment for low back pain in August 1966; an x-ray taken the same day revealed good alignment, transitional x type of vertebra and no other evidence of bony abnormality. He again sought treatment for low back pain in November 1966 and January 1967, where tenderness and pain on flexion were noted. A January 1967 x-ray revealed no abnormality. The Veteran sought treatment for back pain in February 1967; the provider noted some tenderness around L5; deep tendon reflexes were okay and the Veteran could touch his toes. Straight leg raising test was apparently positive; the diagnostic impression was back strain. STRs show the Veteran sought treatment for back pain for a last time in November 1967. An x-ray was negative and there was no tenderness. The diagnostic impression was no pathology. His July 1968 Report of Medical Examination at separation reflects no abnormalities; his contemporaneous Report of Medical History reflects his only reported issue was frequent trouble sleeping. The Veteran had another Report of Medical Examination in March 1969 at entry into the Puerto Rico National Guard; the report reflects no abnormalities and "nothing of significance in medical history of clinical significance." In the contemporaneous Report of Medical History, the Veteran answered "no" to all questions, including a history back trouble. The Veteran filed his first claim regarding the back in May 1976. In connection with this claim, he received a VA examination in July 1976, in which he reported a low back trauma in approximately 1966 and back pain since that time. Physical examination revealed no abnormalities. At the same time, the Veteran received a VA mental health examination. That report reflects that the Veteran had a work-related injury in his position with the State Police in March 1974, a position that he had started in 1970. In the accident, the Veteran reported he fell off a cliff and received multiple wounds; he was rescued with a long rope and was hospitalized for a few days. See also May 2008 VA psychiatry note (Veteran reports an accident in 1974 in which his car "fell through a mountain" and he had a period of loss of consciousness); August 2009 VA psychiatry note (Veteran reports he had an accident while working for the Police department where his car fell down a cliff). The next medical evidence of treatment for the back is a July 2003 VA primary care note in which the Veteran reported acute low back pain since three days prior after sudden movement while walking. He reported that he felt the back "lock" and pain was limiting his movements; he also reported burning sensation in his right thigh. A February 2005 VA primary care note reflects the Veteran reported low back pain for the previous three days after an effort. An April 2007 VA primary care note reflects the Veteran reported occasional low back pain. A January 2009 VA primary care note reflects the Veteran sought treatment for back pain; physical examination revealed intact range of motion, adequate muscle tone, no deformities, and no gross motor or sensory deficit. A study was conducted revealing degenerative joint disease of the lumbosacral spine. The Veteran received an MRI at the VA in March 2009; it revealed multilevel degenerative changes of the lumbar spine, most prominent at the L4 through L5 level where there was moderate narrowing of the left neural foramina. An April 2009 VA treatment note again reflects that physical evaluation showed no loss of range of motion of the lower back; adequate muscle tone, no deformities and no gross motor or sensory deficit. The RO subsequently received a letter from Dr. N.O.V., dated November 2009, in support of the Veteran's claim. The letter reflects the Veteran reported a sensation of locking which limited his movements and pain with movement. He was no longer able to tolerate prolonged sitting or standing and could not lift heavy things, bend, squat, or crawls. The letter also states that the Veteran "started to complain of these symptoms as soon as he returned from service." She also opined that the Veteran's back problems were more likely than not related to his active service duties. The Veteran received a CT scan of the pelvis at the VA in May 2010; it revealed spondylotic changes of the dorsal spine and scattered atheromatous calcifications. A January 2011 VA treatment note reflects the Veteran sought treatment for chronic low back pain. He reported benefits from physical therapy and stated that current pain was a six out of ten. No physical examination was conducted; the assessment was: chronic low back pain, muscle spasms, and lumbar degenerative disc disease. A July 2013 CT scan of the lumbosacral spine revealed multilevel degenerative changes, most pronounced at L3 through L4 and L4 through L5 levels with associated central canal narrowing. Findings were suggesting of a Tarlov cyst involving the left lower sacrum and there were scattered vascular atheromatous changes. A September 2013 lumber spine MRI revealed straightening of the lumbar lordosis which could be position or secondary to muscle spasm; severe degenerative changes of the lumbar spine; and a focal fluid signal intensity abnormality projecting dorsal to S3 vertebral body towards the left side, most likely secondary to an underlying Tarlov cyst. The Veteran received a VA spine examination in May 2016; the examiner thoroughly reviewed the claims file and both interviewed and examined the Veteran. Citing the documentary medical evidence, the examiner provided a negative nexus opinion. In support of this opinion, the examiner noted that although the Veteran was treated for back complaints on active duty, the separation examination report in 1968 was silent for any chronic condition. The re-enlistment examination for the National Guard in 1969 was also silent for any chronic back condition. The examiner noted that the Veteran first filed a claim for a back disability in 1976, seven years after the reenlistment examination was negative. The examiner further noted that the first documentary evidence of medical treatment for back pain, which occurred three days prior after sudden movement, was in 2003 - some 35 years after separation from active duty. The Board finds that the May 2016 VA examination report is highly probative. The Board acknowledges the November 2009 letter of Dr. N.O.V., in which she provides a positive nexus opinion. The Board affords this opinion less probative weight because it appears to be based on the Veteran's own assertions that he sought treatment for back pain immediately following separation from active duty, and in no way addresses the unremarkable VA examination of the spine in July 1976. Dr. N.O.V.'s positive nexus opinion is merely reflective of the Veteran's self-report, as there is no evidence that the Veteran directly reported these symptoms to Dr. N.O.V. contemporaneously in the period immediately following active duty. This is further supported by the Veteran's December 2014 response indicating that he did not receive treatment from Dr. N.O.V.; she evaluated him and reviewed his records twice and the resultant reports were forwarded to the RO. Moreover, there is documentary medical evidence that the Veteran has had back complaints on an intermittent basis only, since 2003. The Board observes that the Veteran's initial claim seeking service connection for a back disability in May 1976 occurred after his March 1975 accident, which occurred while performing duties related to his position with the state police. As noted above, the Board is charged with weighing the evidence of record. In the present case, the Board finds that the preponderance of the evidence shows that his currently diagnosed low back disability did not have onset in service and is not otherwise etiologically related to active duty. In regard to service connection on a presumptive basis for a chronic disease - in this case arthritis - the evidence shows that the Veteran was not diagnosed with arthritis of the lumbosacral spine within one year of separation from active duty. In addition, as noted above, the evidence does not show that he experienced continuity of symptomology since service. Although the Veteran has made lay statements suggesting continuity of symptomatology, the Board affords more probative value to the contemporaneous medical evidence, which shows that the Veteran's back troubles resolved after treatment on active duty, that he denied back problems at separation and at entry into the National Guard, that he had a critical accident while working in the civilian sector many years after service, and that he occasionally sought treatment for back problems after certain traumatic incidents many years after service. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Facts and Analysis - Knees The Veteran asserts that he has a current bilateral knee disability that had onset during service. The record shows current diagnoses of bilateral knee arthritis, satisfying the first element of service connection. The second element, in-service, injury is only met for the left knee. See November 1966 STR showing treatment for left knee pain. The Veteran's July 1966 report of medical history at induction reflects he reported "yes" to current and/or a history of swollen or painful joints, leg cramps, and trick or locked knee, among others. The contemporaneous report of medical examination at entry reflects no abnormalities. The Veteran sought treatment for knee problems only once during service; he complained of left knee pain in November 1966. His July 1968 report of medical examination at separation reflects he reported he was in good health, with no abnormalities documented. The contemporaneous July 1968 report of medical history reflects no joint or knee complaints. The Veteran had another medical examination when he entered the Puerto Rico National Guard in March 1969. No abnormalities were noted and the remarks further indicate, "nothing of importance in medical history of clinical significance." In the contemporaneous Report of Medical History, the Veteran answered "no" to all questions, including a history of trick or locked knee. The Veteran filed his first claim regarding the bilateral legs in May 1976. In connection with this claim, he received a VA examination in July 1976, in which he reported trauma to both legs in approximately 1966 and continued pain since that time. Physical examination of the musculoskeletal system was entirely normal, and no bilateral knee diagnosis was rendered; there were no abnormalities. At the same time, the Veteran received a VA mental health examination. That report reflects that the Veteran had a work-related injury in his position with the State Police in March 1974, a position that he had started in 1970. In the accident, the Veteran reported he fell off a cliff and received multiple wounds; he was rescued with a long rope and was hospitalized for a few days. See also May 2008 VA psychiatry note (Veteran reports an accident in 1974 in which his car "fell through a mountain" and he had a period of loss of consciousness); August 2009 VA psychiatry note (Veteran reports he had an accident while working for the Police department where his car fell down a cliff). Post-service, the first notation of knee treatment in the claims file is a November 2009 letter from Dr. N.O.V. indicating the Veteran presented with bilateral knee pain with periods of swelling and instability, clicking, catching in both knees, and crepitus. The letter indicates the Veteran reported to her that symptoms occurred as soon as he returned from service and stated that he carried heavy items during service putting a lot of stress on "his column." Dr. N.O.V. further stated that this kind of stress causes inflammatory changes, which, with time could produce degenerative disease. She opined that the Veteran's knee problems were probably related to service as a consequence of his duties while in active service. In April 2010 the Veteran had a skeletal scintigram of the entire body; it was ordered by his nuclear medicine physician, related to his prostate cancer diagnosis and treatment. It revealed an increased uptake in several joints, including the knees. A May 2010 VA x-ray of both knees revealed degenerative changes, bilateral suprapatellar effusions, larger on the left side, and right patella alta. In January 2011, the Veteran sought treatment for pain in the knees and ankles. An October 2014 VA x-ray of both knees revealed bilateral mild to moderate degenerative changes, bilateral suprapatellar effusions, larger on the right side, and vascular calcifications. Later in October 2014, the Veteran had an orthopedic surgery consult for right knee pain. The provider noted joint line tenderness, mild varus deformity, and preserved range of motion. Conservative treatment was recommended. There are numerous VA treatment notes which reflect the Veteran received physical therapy for his knees. In May 2016, the Veteran was afforded a VA knees examination. The claims file was reviewed and the provider both interviewed and examined the Veteran, noting current diagnoses of bilateral degenerative arthritis as of 2010. For medical history, the Veteran reported he could not recall when the condition began and that he experienced intermittent bilateral knee pain. He was also using a cane for stability. A complete disability benefit questionnaire (DBQ) was fulfilled with the examination. The examiner provided a negative nexus opinion regarding the relationship between the Veteran's current knee disabilities and service. In support of this conclusion, the examiner noted that the Veteran's one STR showing knee complaints contained only a statement of left knee pain, which was a subjective complaint without treatment or diagnosis on active duty. She further stated that it is well-documented in medical literature that degenerative changes may be considered part of the normal aging process in patients older than 40 years of age. She opined that the Veteran's bilateral knee condition was due to the natural aging process and unrelated to active military service. The Board affords more probative value to the opinion of the May 2016 VA examiner, who reviewed the Veteran's claims file and relevant history, including the unremarkable July 1976 VA examination, noted the Veteran's single complaint of left knee pain during service, correctly pointed out that the Veteran was not treated for any injury and did not receive a diagnosis during active duty, and indicated that the date of onset of the Veteran's knee disability was after service and attributable to the normal aging process. Furthermore, the reports of medical examination and history at separation from service and entry into the National Guard contradict the Veteran's assertions of continuous bilateral knee pain since service. The Board acknowledges the November 2009 opinion of Dr. N.O.V.; however, it is based on the Veteran's self-report of continuous knee symptoms since separation from service. This factual premise is not supported by the other documentary evidence of record. Notably, the Veteran specifically stated he could not identify the date of onset of his bilateral knee complaints during his May 2016 VA examination. As it is based in-part on an inaccurate factual premise, the opinion of Dr. N.O.V. is afforded little probative value. The Board also notes that documentary medical evidence does not show any complaints of a bilateral knee problems until November 2009, some 41 years after separation from service, when the Veteran was 63 years old. Thus, the criteria for service connection on a presumptive basis for a chronic disease, arthritis, are not met. In addition, as noted above, the evidence does not show that he experienced continuity of symptomology since service. Although the Veteran has made lay statements suggesting continuity of symptomatology, the Board affords more probative value to the contemporaneous medical evidence, which shows that the Veteran's documented in-service left knee pain resolved, that he denied knee problems at separation and at entry into the National Guard, that he had a critical accident while working in the civilian sector many years after service, and that he sought treatment for bilateral knee problems many years after service. As a result of the foregoing, the Board finds that the preponderance of the evidence shows that the Veteran's bilateral knee disability did not have onset during service, did not manifest to a compensable degree within one year of separation from service, and is not otherwise related to service. Specifically, the Board finds that the preponderance of the evidence shows that the bilateral knee disability is due to the natural aging process. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz, supra; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Principles of Rating Disabilities Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations is to 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. Under 38 C.F.R. § 4.130, Diagnostic Code 9434, which pertains to the Veteran's depressive disorder, a 30 percent rating is warranted where the disorder is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routing behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9434. A 50 percent rating is warranted where the disorder is manifested by 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 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. 38 C.F.R. § 4.130, Diagnostic Code 9434. A 70 percent rating is warranted where the disorder is manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and an inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434. A 100 percent rating is available for more severe manifestations. Ratings of psychiatric disabilities shall be assigned 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. Further, ratings are assigned according to the manifestation of particular symptoms. However, the various symptoms listed after the terms "occupational and social impairment with deficiencies in most areas" and "total occupational and social impairment" in 38 C.F.R. § 4.130 are not 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. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996). Facts and Discussion - Depressive Disorder In the Veteran's November 2011 VA examination report for prostate cancer, he reported depressive symptoms secondary to this service connected condition. From the examination report, the AOJ inferred a claim for service connection depressive disorder secondary to prostate cancer. In a March 2012 rating decision, the AOJ granted the Veteran's inferred claim. That rating decision clearly indicates that a 30 percent rating was warranted; however the accompany code-sheet reflects that only a 20 percent evaluation was implemented. Although the contemporaneous code-sheet suggests that original grant for depressive disorder was on an aggravation basis, i.e., his psychiatric disability is aggravated by his service-connected prostate cancer, the narrative rating decision does not discuss the baseline level for the Veteran's depressive disorder prior to aggravation by his prostate cancer. Thus, it appears as though the AOJ's implementation of a 20 percent rating was in error and he should have been awarded a 30 percent rating since the initial date of the inferred claim, November 8, 2011. The Veteran subsequently submitted a statement in May 2012 regarding his depressive disorder. Although the AOJ interpreted the Veteran's statement as a new claim for an increased rating, the Board liberally interprets the Veteran's May 2012 statement as a Notice of Disagreement regarding the 30 percent evaluation actually assigned in the March 2012 rating decision. 38 C.F.R. § 20.201. Accordingly, a 30 percent rating is currently in effect for the Veteran's depressive disorder for the entire appeal period, which begins in November 2011. The matter now before the Board is whether a rating in excess of 30 percent is warranted at any point during this appeal period. Although the appeal period begins in November 2011, the Veteran's earlier psychiatric medical history is also relevant. Several VA treatment notes in 2007 reflect the Veteran complained of insomnia, anxiety, occasional nightmares, restlessness, irritability, verbal outbursts, depression, loss of energy, and auditory hallucinations. His mental status examinations included a depressed and anxious mood and delusional thoughts; all other areas were within normal limits. Private treatment notes of private provider Dr. F.L. dated late 2007 and early 2008 are substantially similar except that they also indicate the Veteran's concentration was less than adequate and affect was restricted. A May 2008 VA psychiatry note reflects the Veteran had not been taking his medications for three to six months. He reported avoidance behaviors due to Vietnam War experiences but denied auditory and visual hallucinations, delusions, and homicidal and suicidal thoughts. Mental status examination was basically within normal limits including mood, concentration, memory, insight and judgment. The primary diagnosis was anxiety disorder, which the provider noted was symptomatic but improving with medications. GAF was 60. By October 2008, the Veteran reported that he felt increased depression due to being denied disability compensation; he was not taking his medications but acknowledged that he felt much better when he was on medications. He reported feeling low energy, low motivation, low interest, sadness, and hearing noises. He denied suicidal and homicidal ideation, intention or plan and also denied auditory and visual hallucinations and delusions. Mental status examination was notable for depressed mood, constricted affect, thought process impacted by latency of responses and intermittent staring. The Veteran denied auditory and visual hallucinations and no illusions or delusions were apparent. The primary diagnosis was anxiety disorder and GAF was 60. A January 2009 VA psychiatry note reflects the Veteran discussed his frustration with the VA disability compensation system. He was only partially complaint with medications but acknowledged that he felt better while on such medications. He reported feeling sad, irritable at times, low energy, low motivation, low interest and insomnia; he also reported that he enjoyed reading any book. The Veteran denied auditory and visual hallucinations and also denied homicidal or suicidal ideations. Mental status examination was notable for depressed mood, constricted affect, thought process with latency of responses and staring episodes. Primary diagnosis was anxiety disorder; GAF was 60. An August 2009 VA psychiatry note reflects the Veteran came for an unscheduled visit; he was having trouble sleeping and reported that he had the sensation of being watched. He also reported hearing noises, with nothing there when he looks. The Veteran stated his appetite was decreased and that he had episodes of extreme irritability and grouchiness. He also stated that he did not like to be alone. The Veteran reported that he had an accident while working with the Police Department where his car fell down a cliff and that he had experienced anxiousness ever since. He reported that he had been diagnosed with schizophrenia soon after the incident and received a disability retirement from the police. Mental status examination was notable for depressed mood; blunted affect; presence of auditory hallucinations and paranoid ideas. The provider indicated the Veteran presented with mild deterioration of his condition. Diagnoses were schizophrenia, paranoid type and depressive disorder; GAF was 50. An October 2009 VA psychiatry note reflects the Veteran reported an increase in flashbacks from Vietnam after a recent explosion. He reported he continued to have trouble sleeping and that he was still sensitive to noise. He still felt as though he was being watched and followed. Mental status examination was notable for depressed mood, blunted affect, auditory hallucinations, paranoid ideas, and non-spontaneous speech. Diagnoses were schizophrenia, paranoid type and depressive disorder; GAF was 50. In December 2009 the Veteran reported that his sleep had improved although he still had nightmares. He continued to be sensitive to noises and feel that he was being watched. The Veteran reported that he preferred to stay at home and that when he did go out, he became anxious and got an urge to go back home. He reported hearing voices, screaming and whisperings, which caused anxiety and impacted sleep. He denied any homicidal or suicidal ideas. Mental status examination was notable for depressed mood, blunted affect, auditory hallucinations, and paranoid ideas. Diagnoses were schizophrenia, paranoid type and depressive disorder; GAF was 50. VA psychiatry notes from March 2010 and June 2010 reflect the Veteran reported that he continued to struggle with nightmares, anxiety, the sensation of being watched, and auditory hallucinations. He denied suicidal or homicidal ideations but stated that sometimes wished to die because he felt like he was burdensome and old; he denied any plans for suicide. Mental status examination was notable for constricted mood, auditory hallucinations, and paranoid ideas. Diagnoses were schizophrenia, paranoid type and depressive disorder; GAF was 50. By September 2010, the Veteran reported improvement; his nightmares were practically gone although he continued to have an apprehensive sensation. He denied ideas of homicide and suicide. Mental status examination was notable for constricted affect; there were no auditory hallucinations or paranoid ideas. Diagnoses were schizophrenia, paranoid type and depressive disorder; GAF was estimated as 55 to 60. A December 2010 VA psychiatrist note reflects GAF was at 60; there were no suicidal or homicidal ideations and no hallucinations or paranoia. A number of symptoms, including increased nightmares and feelings of being traced returned as of May 2011. Mental status examination was notable for dysthymic mood, restricted affect, racing thoughts, auditory hallucinations, and paranoid ideas. Diagnoses were schizophrenia, paranoid type and depressive disorder; GAF was 60. With similar symptoms, GAF was reduced to 55 in August 2011. A January 2012 VA treatment note reflects that the Veteran's mother had recently passed and that she was being buried the day of the appointment. She had been living with the Veteran and his spouse prior to her death. The Veteran was feeling more depressed; he reported nightmares about being shot. Mental status examination was remarkable for depressed mood, restricted affect, auditory hallucinations, and persecutory ideas. Diagnoses were schizophrenia, paranoid type, depressive disorder, and bereavement; GAF was 55. An April 2012 letter from Dr. N.O.V. reflects the Veteran presented with episodes of excessive anxiety and worry, restless, easily fatigued, muscle tension, difficulties with concentration, and episodes of irritability which interfered with daily living. Other symptoms noted include frequent mood changes, decreased interest and pleasure in most usual activities, frustration, isolative behavior, and changes in sleep and eating patter. Dr. N.O.V., using the VA regulatory language, opined that the Veteran's symptoms were manifested by occupational impairment with reduced reliability and productivity due to symptoms of flattened affect, episodes of panic attacks, impaired short-term memory, and sometimes forgetting names and things he used to do on a daily basis. A month later, in a May 2012 VA psychiatry appointment, the Veteran reported feeling isolated, persistence of nightmares, and dreams about his parents. Mental status examination was notable for depressed mood, restricted affect, and auditory hallucinations (but less frequent). It specifically notes that recent memory and remote memory were intact. Diagnoses were schizophrenia, paranoid type, depressive disorder, and bereavement; GAF was 55. Symptoms were substantially similar in September 2012, except that his depressed mood had improved a little. The note reflects the Veteran's bereavement had mostly resolved; GAF was 60. VA psychiatry notes from March, June, and September 2013 reflect the Veteran continued to report episodes of isolation and nightmares. The June treatment note reflects the Veteran stated nightmares were about being chased or followed, about tragedies, or about his deceased father reprimanding him. Mental status examinations were notable for depressed mood, restricted affect, and continued, but less frequent, auditory hallucinations. GAF was 60. VA treatment notes from February, June, and November 2014 reflect the Veteran was struggling with his physical conditions; he reported that sleep had improved although he was still having episodes of isolation. Mental status examination was notable for depressed mood and restricted affect. There were no auditory hallucinations or persecutory ideas. The provider indicated the Veteran continued to be symptomatic but less so than in the past. GAF was 60. Several PHQ-2 depression screens conducted in October and November 2014 were negative for depression. In January 2015, the Veteran was afforded a VA mental disorders examination. The provider reviewed the Veteran's claims file and personally interviewed him. The diagnostic impression was depressive disorder NOS with no additional psychiatric diagnoses. Symptoms noted included depressed mood, trouble sleeping with frequent awakenings due to nightmares, fearfulness, socially withdrawal, and psychological distress at cues that remind him of his military tour. The provider opined that the Veteran's depressive disorder was manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. She did not comment on the Veteran's documented history of intermittent auditory hallucinations. Subsequent VA psychiatry notes are substantially similar to those in 2014. The Veteran's depressive disorder continued to be manifested by depressed or dysthymic mood, restricted affect, nightmares, sleep trouble, and isolative tendencies. An October 2015 VA treatment note reflects symptoms worsened somewhat when the Veteran ran out of medications; however, the auditory hallucinations and persecutory ideas did not return at that time. The diagnostic impression in October 2015 and March 2016 were recurrent major depressive disorder, mild to moderate. The Veteran received another VA psychiatric examination in May 2016 primarily for the purpose of determining whether he had a PTSD diagnosis under the DSM criteria. The provider reviewed the claims file and personally interviewed the Veteran. The diagnostic impression was unspecified depressive disorder, alone. The examiner noted that the Veteran had good family relations with his parents and siblings and that his parental unit had remained intact. He had married his spouse in August 1970 and was still married; family relations were described as good. The Veteran reported receiving retirement/pension benefits from the state police since 1978 after nine years working with the force. Then-current psychiatric symptoms reported by the Veteran included: depressed mood, anxiety, and chronic sleep impairment. The Veteran also reported that he disliked being in enclosed spaces and that he did not like rainy days or lightening because they reminded him of Vietnam. The examiner opined that the Veteran's depressive disorder was manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. Considering the rating criteria in 38 C.F.R. § 4.130, the Board finds that the Veteran's symptoms and manifestations correspond with a 50 percent rating, and no higher, throughout the appeal period. Initially, to the extent the record reflects other diagnoses in addition to depressive disorder, the evidence of record does not sufficiently distinguish the symptoms of these disorders from his service-connected depressive disorder. Thus, the Board's instant discussion attributes all of the Veteran's mental health symptoms to his service-connected depressive disorder. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Both VA examinations during the appeal period indicated that the Veteran's depressive disorder as manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. Additionally, the Veteran's depressive disorder has been manifested by depressed mood, occasional anxiety, chronic sleep impairment with nightmares, and a tendency to isolate himself. The evidence reflects he has several meaningful interpersonal relationships. However, given the Veteran's intermittently reported auditory hallucinations and delusional thoughts of being followed and/or watched and GAF scores demonstrative of moderate symptomatology, the Board affords him the benefit of the doubt and assigns a 50 percent rating throughout the appeal period. 38 C.F.R. § 4.7. A rating in excess of 50 percent is not warranted, as the Veteran has not demonstrated any symptomatology enumerated in the criteria for 70 or 100 percent ratings or any other symptomatology of similar severity, frequency, and duration. His hallucinations have not been persistent, and do not significantly impact his social functioning. He has been married to the same spouse for 47 years and he reports a good relationship. Evidence also suggests the Veteran has a positive relationship with his extended family. Moreover, his spouse frequently attends his VA psychiatry appointments with him. Impact on potential occupational function is not apparent, as the Veteran has been medically retired from work since prior to the appeal period. Accordingly, a 50 percent rating, but no higher, is warranted. Special Monthly Compensation The Veteran is currently in receipt of a 100 percent rating for prostate cancer, and now has additional service-connected disabilities independently ratable at 60 percent. Thus, SMC at the housebound rate is warranted. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). As SMC based on the need for aid and attendance is a greater benefit than housebound benefits, discussion of entitlement to SMC based on need for aid and attendance is not moot. Under 38 U.S.C.§ 1114(l), special monthly compensation is payable if, as the result of service-connected disability, the Veteran is permanently bedridden or so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). As directed by 38 C.F.R. § 3.352(a), the following criteria are to be considered for determining whether a claimant is in need of the regular aid and attendance of another person: (1) the inability of the claimant to dress himself or herself or to keep himself or herself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliance which, by reason of the particular disability, cannot be done without aid (not to include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); (3) the inability of the claimant to feed himself or herself through the loss of coordination of the upper extremities or through extreme weakness; (4) the inability to attend to the wants of nature; or, (5) a physical or mental incapacity that requires care and assistance on a regular basis to protect the claimant from the hazards or dangers incident to his or her daily environment. 38 C.F.R. §§ 3.350 (b)(4), 3.352(a). Here, the record does not reflect, and the Veteran does not assert, that he is permanently bedridden. Moreover, the Veteran is independent in his activities of daily living, and is not physically or mentally incapacitated due to service-connected disabilities such that he requires care and assistance on a regular basis to protect him from any hazards or dangers incident to his daily environment. The December 2012 VA examiner specifically stated that the Veteran was able to perform all self-care functions and was unrestricted in his ability to leave the home. While the Veteran referenced needing assistance with dressing, he attributed this to his lower back disability, which is not service-connected as indicated above. More recent VA treatment notes do not suggest the Veteran's condition has deteriorated significantly in this regard since the 2012 VA examination. As the criteria are not met, entitlement to SMC at the A&A rate must be denied. Since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. ORDER Entitlement to service connection for PTSD is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a bilateral knee disability is denied. Entitlement to a 50 percent rating, but no greater, for depressive disorder is granted from November 8, 2011. SMC at the housebound rate is granted. SMC at the A&A rate is denied. ______________________________________________ S. BUSH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs