Citation Nr: 18141876 Decision Date: 10/11/18 Archive Date: 10/11/18 DOCKET NO. 99-13 744A DATE: October 11, 2018 ORDER Entitlement to an initial rating of 70 percent for posttraumatic stress disorder (PTSD) with alcohol and substance abuse from December 23, 1997, through July 26, 2006, and from November 1, 2006, through August 27, 2009 is granted, subject to controlling regulations applicable to the payment of Department of Veterans Affairs (VA) monetary benefits. Entitlement to a total disability rating based on individual unemployability due to service-connected PTSD with alcohol and substance abuse is granted from December 23, 1997, to July 26, 2006, and from November 1, 2006, through August 27, 2009, subject to controlling regulations applicable to the payment of VA monetary benefits. FINDINGS OF FACT 1. For the time periods from December 23, 1997 through July 26, 2006, and from November 1, 2006 through August 27, 2009, the Veteran’s PTSD has been manifested by occupational and social impairment with deficiencies in most areas. 2. From December 23, 1997 through July 26, 2006, and from November 1, 2006 through August 27, 2009, the Veteran’s service-connected PTSD has been rated as 70 percent disabling. 3. The Veteran is unable to secure or follow a substantially gainful occupation consistent with his high school education with one or two years of college and usual occupation as a semi-truck driver due to service-connected PTSD. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, the criteria for entitlement to an initial rating of 70 percent for PTSD with alcohol and substance abuse from December 23, 1997 through July 26, 2006, and from November 1, 2006 through August 27, 2009 have been more nearly approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 2. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to a total disability rating based on individual unemployability due to service-connected PTSD with alcohol and substance abuse have been met from December 23, 1997 through July 26, 2006, and from November 1, 2006 through August 27, 2009. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1974 to April 1976 and from June 1976 to June 1978. He also served from May 1980 to March 1984, but received an other than honorable discharge from this period of service. This matter comes before the Board of Veterans’ Appeals (Board) from an April 2009 rating decision, which granted service connection for PTSD and assigned a temporary total percent rating (TTR) effective July 27, 2006, and a 50 percent rating from November 1, 2006. A December 2009 rating decision granted another TTR, effective August 28, 2009, followed by a 100 percent schedular rating for PTSD with alcohol and substance abuse effective December 1, 2009. The Veteran disagreed with the effective date assigned for the award of service connection for PTSD and with the initial 50 percent rating assigned prior to August 28, 2009. In October 2014, the Board granted an earlier effective date of December 23, 1997 for the grant of service connection for PTSD. At that time, the Board also remanded the issues of entitlement to an initial rating in excess of 50 percent for PTSD prior to August 28, 2009 and entitlement to a TDIU prior to August 28, 2009. In a December 2014 rating decision, the regional office (RO) effectuated the October 2014 Board decision, granting an earlier effective date of December 23, 1997 for service connection for PTSD and assigned an initial 10 percent rating. The Veteran disagreed with the 10 percent rating assigned for PTSD from December 23, 1997 through July 26, 2006 and perfected a timely appeal. In December 2015, the Board granted an initial 50 percent rating for PTSD for the period from December 23, 1997 through July 26, 2006, denied an initial rating in excess of 50 percent for PTSD from November 1, 2006 through August 27, 2009, and dismissed the issue of entitlement to a TDIU prior to August 27, 2009. In January 2018, the Board received a Motion to Vacate the December 2017 Board decision from the Veteran’s attorney on his behalf, except for the portion of that decision that granted a 50 percent rating for the period from December 23, 1997 through July 26, 2006. In March 2018, the Board granted the Motion, vacating the December 2017 Board decision to the extent that it denied an initial rating in excess of 50 percent for the periods from December 23, 1997 through July 26, 2006, and from November 1, 2006 through August 27, 2009, and dismissed the issue of entitlement to a TDIU prior to August 28, 2009. 1. Entitlement to an initial rating in excess of 50 percent for PTSD with alcohol and substance abuse from December 23, 1997 through July 26, 2006, and from November 1, 2006 through August 27, 2009 The Veteran contends that an initial rating in excess of 50 percent is warranted for service-connected PTSD. Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings should be applied, the higher rating 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 determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Generally, when an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are also for consideration in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claim. The Veteran’s PTSD has been rated as 50 percent disabling from the date service connection was established, effective December 23, 1997 through July 26, 2006, and from November 1, 2006 through August 27, 2009, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, which uses the General Rating Formula for Mental Disorders. A 50 percent evaluation is for assignment when there is 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 establishing effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is contemplated 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 when there is evidence of 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 and place; memory loss for names of close relatives, own occupation or name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the 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. 38 C.F.R. § 4.126. The symptoms listed in the relevant rating criteria are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In assessing the evidence of record, it is important to note that 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.” See Richard v. Brown, 9 Vet. App. 266, 267 (citing Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 32 (4th ed. 1994)). In this regard, the Board notes that effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated DSM Fifth Edition (DSM-5), and examinations conducted pursuant to the DSM-5 do not include GAF scores. Because the applicable time periods on appeal occur prior to the regulatory amendments, the Board will consider the GAF scores in adjudicating the claims. During the periods from December 23, 1997 through July 26, 2006 and from November 1, 2006 through August 27, 2009, the Veteran’s GAF scores ranged from 45 to 62. GAF scores ranging from 61 to 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. DSM-IV at 32. GAF scores ranging from 51 to 60 indicate 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 peer or coworkers). Id. GAF scores ranging from 41 to 50 indicate 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). Id. GAF scores are just one component of a veteran’s disability picture, and the Board does not have a “formula” that it follows in assigning evaluations. Rather, the Board considers the Veteran’s entire disability picture, including GAF scores. Under such circumstances, Veterans with identical GAF scores may be assigned different evaluations based on each individual’s symptomatology and level of functioning. Furthermore, the Board need not accept a GAF score as probative. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995) (it is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others). By way of history, service connection for PTSD was eventually granted effective from December 23, 1997 and attributed to events the Veteran witnessed during his participation in the contiguous water of the Republic of Vietnam during Operation Frequent Wind in April 1975, involving the evacuation of thousands of Americans and others from Saigon, and during Operation Eagle Pull in April 1975, which involved the evacuation of 287 U.S. and foreign nationals from Phnom Penh, Cambodia. The evidence of record also documents the Veteran’s reports of childhood physical abuse and using alcohol since age 14, and a post-service stressor involving the Veteran’s 1993 murder of his common-law wife and another man. Although the evidence of record contains conflicting statements by the Veteran to treatment providers and to VA personnel in the course of seeking VA compensation benefits regarding the proper rating for his PTSD, the Board recognizes that when it is not possible to separate the effects of a nonservice-connected disorder from those of a service-connected disorder, reasonable doubt should be resolved in the claimant’s favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.102; Mauerhan v. Principi, 16 Vet. App. 436 (2002) (factors listed in the rating formula are examples of conditions that warrant a particular rating and are used to help differentiate between the different evaluation levels). Therefore, to the extent the Board is unable to discern whether the Veteran’s PTSD symptoms at any given time relate to his military stressors or non-service related stressors, the Board resolves doubt and attributes the symptoms to military stressors. Turning to the evidence, in connection with his December 1997 claim for service connection, the Veteran was afforded a VA PTSD examination in May 1998; however, he failed to report to the examination without explanation. A July 2000 VA psychiatry note reflects the Veteran’s report that he had been incarcerated for the past three years because he violated the terms of his probation for the original offense of murder in 1993. He stated that he was unable to attend his appointment scheduled in June because he had been arrested for public intoxication. He reported current symptoms of feeling depressed, having trouble staying asleep, and low interest. He denied suicidal or homicidal ideation. He described prior work history at the Social Security Administration and in construction. Mental status examination findings included the following: alert and oriented [to person, place, and time]; normal behavior and movements; established good rapport with interviewer; speech normal in rate and tone; mood described as “pissed about everything,” believing that he “gave a lot and got very little back;” middle-range, slightly angry-looking, and non-labile affect; linear thought process; cognition grossly intact; and insight and judgment good. The examiner commented that the Veteran “did not mention any [symptoms] of PTSD.” The assigned GAF score was 59. In August 2000, the Veteran participated in a psychological evaluation relating to his claim for SSA disability benefits. He reported completing twelfth grade and one year of college and described prior work history as a dump truck driver, construction worker, and records and analyst clerk for SSA. He identified a legal history involving several arrests and an incarceration from which he was released in March 2000. He self-identified as having a propensity for violence when he misses his medication, including Trazadone and Wellbutrin for psychiatric symptoms. He indicated that his fiancé was his only friend and that he attended church twice monthly. He described his sleep as “okay” with medication. Mental status examination findings included the following: alert and fully oriented; polite and cooperative demeanor with good eye contact; full affect and pleasant mood with no indications of depression, anxiety, or mania; coherent and relevant speech; no evidence of blocking, muteness, repetitions, flight of ideas, loosening of associations, tangentiality, circumstantiality, or confusion in thought process; no evidence of hallucinations, delusions, ideas of reference, phobias, or obsessions or compulsions; adequate task attentiveness; intact recent and remote memory; attention span, concentration, and general fund of knowledge in the low average range; limited insight and judgment; and limited ability to adjust to day-to-day situations. The examiner summarized that the Veteran appeared to function in the average range of verbal and intellectual ability and cognitive functioning appeared adequate such that he “should have no difficulties with understanding, carrying out, or remembering instructions.” The examiner stated that clinical presentation indicated the Veteran would likely respond appropriately to supervision and he had adequate social skills to relate well to coworkers. However, he reported significant problems in social functioning. He could likely handle mild work pressures in a work setting. He appeared capable of functioning independently, but would need assistance managing his financial affairs due to history of alcohol abuse and continued use of alcohol. A September 2000 intake report from a VA outpatient substance abuse clinic (OSAC) reflects the Veteran’s request for treatment of alcohol abuse and housing assistance to satisfy a court order related to his probation. He reported he had resumed drinking three months after release from incarceration and had violated his probation by drinking and assaulting his girlfriend’s son, who was reportedly assaulting her. He disclosed a family history of physical abuse, chemical abuse, and psychological problems, stating that he struggles to overcome those early experiences. He also reported his history of PTSD associated with his military service in Vietnam. He indicated he completed 14 years of education and 8 months of technical training, he did not have a valid driver’s license, his longest full-time job was 12 years, and his last occupation was concrete finisher. In the past 3 years, his employment had been in a controlled environment. On mental status examination, there were no signs or symptoms of psychosis or other thought disorders elicited, he appeared to have above average intelligence, and appeared to be knowledgeable and motivated about substance abuse recovery. He denied current suicidal or homicidal ideation, but endorsed both in the past. He denied problems with attention, recall, or memory and denied problems with anger management, explaining he had taken numerous anger management courses and had learned to control this problem. During an October 2000 VA psychiatry visit, the Veteran complained of periods of amnesia for three to four years, occurring three to four times per year. He described losing time for three hours at a time and discovering he had walked miles away or found himself in a new location, not recalling how he got there. The assessment included rule out amnestic problem versus psychogenic amnesia. Private treatment records dated in November 2000 document that the Veteran was hospitalized after he was transferred from a VA emergency department because he had been beaten in the head with a lead pipe by his girlfriend’s son. The discharge diagnosis was closed head injury with left frontal skull fracture. During a March 2001 VA neurology consultation, the Veteran described his “blackout spells,” stating he had had them for 25 years, but they became very frequent since the November 2000 head trauma. He reported a history of head concussion at age 15 and head trauma in 1975. The neurologist ordered an EEG to rule out seizures or other functional etiologies of the “spells of altered awareness.” The EEG was reported as normal during the awake, drowsy, and light sleep states. In July 2001, the Veteran received VA emergency care for a laceration to his forearm after putting his arm through a window in anger. In August 2001, the Veteran presented to VA urgent care requesting help for his substance abuse. He indicated he had been sober for over a year until he relapsed. He described experiencing a lot of personal stress in his significant relationship at the time he relapsed, but also admitted having fear regarding blackouts and absence of memory, lasting from 15 minutes to 4 hours at a time, which began approximately two months after his severe head injury in November 2000. The Veteran completed a VA neuropsychological assessment in September 2001, which included an interview; behavioral observations; and intelligence, memory, and neuropsychological testing. The clinical psychologist concluded that the results of sensitive measures suggested the possibility of very mild impairment in brain functioning, but overall intelligence was normal and memory abilities were above average. He reported that etiology of any impairment might be related to the head injury sustained last year, particularly if, as the Veteran reported, the injury was sufficiently severe to result in a seizure disorder. However, the history of alcohol dependence could also be a contributing factor. The psychologist related that the Veteran was cognitively capable of competitive employment and seemed able to profit from vocational rehabilitation and training. Subsequent VA treatment records reflect that the Veteran received cognitive therapy beginning in September 2001 to address impairments associated with the November 2000 traumatic brain injury (TBI). In September 2001, the Veteran also completed vocational rehabilitation screening. He reported having problems with headaches, blackouts, weight loss, seizures with uncontrollable bowel movements, trouble sleeping, short-term memory loss, and social anxiety disorder. The psychologist concluded that based on a review of the medical records and present evaluation, the Veteran’s physical and psychiatric symptoms currently impair him in being able to meet the demands of work on a sustained basis in a competitive work environment. Instead, he was accepted into the incentive therapy program. During a November 2001 PTSD screening, the Veteran endorsed depressed and anxious mood, mood lability with anger outbursts, memory lapses, profound feelings of guilt and shame, insomnia, anxiety in social situations, and recent suicidal ideation without intent or plan. Regarding PTSD symptoms, the Veteran reported that the events that led to his incarceration had “replaced” his previous re-experiencing symptoms related to traumatic events in Vietnam. He described having recurrent and intrusive memories, and related symptoms of insomnia, depression, isolation, hyperarousal, and irritability related to the 1993 events. On mental status examination, he was alert and fully oriented; pleasant, cooperative, and soft-spoken; affect was flat and consistent with mood; he became visibly upset and teary when discussing the events of 1993; speech, motor behavior, thought process, and thought content were within normal limits; and judgment and insight were fair to good. The assigned GAF score was 55. A February 2002 disability determination and transmittal from the Social Security Administration found the Veteran to be disabled for SSA purposes based on the primary diagnosis of recurrent major depression and the secondary diagnosis of PTSD. SSA found the Veteran’s disability began November 19, 2000, the date he was hospitalized for a closed head injury. A February 2002 VA mental health note reflects the Veteran’s complaint that he continued to have trouble falling asleep; however, he reported that since he had been on Depakote for six months for his seizure disorder, he noticed his anger had been less explosive. He discussed the death of his common-law wife, became tearful, and expressed shame. Objectively, his mood was dysthymic and his affect was tearful and sad, congruent with his mood. The assigned GAF score was 45. He was admitted to a VA PTSD day treatment program and generally attended PTSD groups regularly until January 2003. During a September 2002 psychiatric evaluation, the Veteran stated he was afraid he was going to hurt someone because he had experienced increased irritability and hostility for the past few weeks. At the same time, he started having “recurring nightmares of his overseas duty” and his “old murder case.” He admitted having an episode of rage in the VA cafeteria the previous day and being asked by security to go home. On mental status examination, his mood was irritable; affect was anxious and depressed; and his speech was slowed. He endorsed auditory hallucinations over the last few weeks involving his common-law wife’s last words. The psychiatrist remarked that while the Veteran had fears that he would harm someone, he “never wants to lose control like that again.” The assigned GAF score was 45. In November 2002, the Veteran was given a brief evaluation of mental health status at the request of the Vocational Rehabilitation Program. Reported results of a psychological assessment and health survey indicated “severe emotional distress or depression.” In April 2003, the Veteran reported he had run out of Gabapentin for seizure control a couple weeks earlier and had experienced insomnia ever since. The psychiatrist renewed the Gabapentin prescription. Mental status examination findings included alert and fully oriented appearance, no exacerbation of psychotic features, mood described as feeling “okay,” constricted affect, no psychomotor agitation or retardation, goal-directed thought process, good eye contact, fair to poor insight and judgment, and good impulse control during interview. During an April 2004 VA psychiatry visit, the Veteran reported doing well and continuing to participate with the Escort Services at a VA medical center (VAMC) through Vocational Rehabilitation. He described having increased depressive symptoms with anhedonia and difficulty initiating activities and asked whether his Celexa (citalopram) could be increased. Mental status examination findings were similar to those reported in April 2003. He denied suicidal or homicidal ideas, intent, or plans and had no formal thought disorder. His dose of Celexa was increased. At a July 2004 follow-up visit, he endorsed intermittent insomnia, but denied anhedonia and lack of interest or energy. Findings on mental status examination were unchanged from those reported during the previous appointment. In December 2004, the Veteran reported “doing well,” although he still experienced intermittent insomnia, and the VA psychiatrist renewed his Risperdal and Celexa medications. During a June 2005 follow-up visit with his VA psychiatrist, the Veteran continued to report doing well and denied having current anhedonia and lack of interest or energy; psychotic features; or suicidal or homicidal ideas, intent, or plans. Objectively, he had constricted affect, fair to poor insight, and fair judgment and impulse control during the interviews. In August 2005, the Veteran told a VA primary care physician that he planned to travel to the Philippines because he had children there and was going to get married. The physician asked the Veteran to advise his psychiatrist of his travel plans. In September 2005, PTSD and depression screening was negative, with the Veteran denying PTSD or depression symptoms within the past month. The Veteran was afforded a VA examination November 2005. Following a review of the claims file and examination of the Veteran, the Axis I diagnosis was polysubstance dependence in current remission and cognitive disorder, the Axis II diagnosis was mixed personality disorder with Cluster B traits, and the assigned GAF score was 62. The psychiatrist concluded that the Veteran did not currently exhibit symptoms of PTSD, including due to identified stressors related to Operations Eagle Pull and Frequent Wind during his first period of service. The psychiatrist noted it was “clear that the Veteran’s substance addiction and disturbance of mood and behavior worsened during his active duty times, particularly during the time of his third” period of service characterized as other than honorable, but the examiner could find no evidence that the active duty experiences caused those conditions. Instead, the psychiatrist concluded that the majority of the Veteran’s symptoms and related dysfunctions were related to his diagnoses of polysubstance dependency and personality disorder. However, to the extent that subsequent RO and Board decisions granted service connection for PTSD and an earlier effective date based, in part, on some medical opinion evidence concluding that the Veteran, in fact, did have PTSD related to events during his service in Vietnam, the Board will consider the mental status examination findings from the November 2005 VA examination. The examiner indicated that since completing a VA alcohol and drug treatment program in 2001 and remaining “almost drug-free,” the Veteran had experienced a corresponding decrease in mood and behavioral disturbance and was comparatively better-adjusted in recent years. In addition to treatment records reflecting these findings, the Veteran himself endorsed this opinion. On mental status examination, the Veteran was appropriately dressed, able to maintain personal hygiene, and oriented to person, time, and place. His attitude toward the examiner was “manipulative, guarded.” Speech and psychomotor activity were unremarkable. The Veteran did “not evidence significant mood dysphoria,” but affect was constricted. He was easily distracted. Thought process and content were unremarkable with no delusions. Judgment was intact, intelligence was average, and the Veteran had some insight to his problems. The Veteran had mild sleep impairment, which had improved since he was “not using as much.” He denied having obsessive or ritualistic behavior, panic attacks, or current suicidal or homicidal ideation, and the examiner observed he had good impulse control. The examiner noted the Veteran’s remote history of very strong violence and its effects on the Veteran’s motivation and mood, and his history of suicidal and homicidal thinking and behavior that had usually been related to substance abuse or addiction. Finally, the Veteran had “minimal cognitive defects” manifested by mildly impaired remote, recent, and immediate memory. Subsequent VA treatment records show that the Veteran continued to participate in an incentive therapy program working as an escort at a VA Medical Center through Vocational Rehabilitation and that he functioned well in the program with some supervision. The records document that he reported to the job assignment on time, his hygiene and appearance were good, and he got along well with peers and staff. During an April 2008 VA psychiatry visit, the Veteran reported doing well and denied anhedonia, lack of interest of energy, or psychotic features. A July 2008 VA psychiatry note reflects that the Veteran was evaluated at the request of police after being peripherally involved in an incident involving a firearm on station earlier in the day. He had been under the impression that he and a co-veteran were going to a casino and in preparation for the trip, the co-veteran asked the Veteran to carry a firearm and ammunition while they were travelling. The co-veteran instead drove to a VAMC, jumped out of the car, and went to a vocational rehabilitation case manager’s office. The police confiscated the Veteran’s gun and requested evaluation. The Veteran’s breathalyzer results were .084 and he reported having a few beers earlier in the day. He did not appear and interact in an intoxicated or impaired manner and was able to relate details to the psychiatrist and police in a coherent and consistent manner. He was not psychotic, depressed, suicidal, or homicidal, and he reported compliance with his medications. The Veteran had not been driving and planned to take city transportation or contact a friend to return to his residence. Later that afternoon, the Veteran appeared at his vocational rehabilitation case manager’s door “very nervous, hands trembling more than usual, strong odor of alcohol, angry facial expression.” Another veteran in the hallway had accused the Veteran of having a gun. The police escorted the Veteran to another location for questioning, along with the contents of a green duffle bag. The Veteran was discharged from the vocational rehabilitation incentive therapy work program the next day due to non-compliance and use of alcohol. The Veteran was afforded another VA examination in December 2008. He endorsed PTSD symptoms such as distressing dreams, efforts to avoid recollections of the trauma, feeling detached from others, sleep impairment, and irritability and anger outbursts. He denied obsessive/ritualistic behavior, panic attacks, or suicidal or homicidal thoughts. Mental status examination findings included the following: clean, neatly groomed appearance; oriented to person, time, and place; slow speech; cooperative, friendly attitude; depressed mood with normal affect; intact attention; unremarkable thought process and content with no delusions or hallucinations; intact insight and judgment; average intelligence; good impulse control; and normal remote and immediate memory with mildly impaired recent memory. The Veteran reported that within the last year, he was no longer working through the incentive therapy program with VA vocational rehabilitation. The diagnosis was chronic, moderate PTSD with an assigned GAF score of 60. The examiner concluded the Veteran’s PTSD resulted occupational and social functioning with reduced reliability and productivity. During a December 2008 call with vocational rehabilitation staff, the Veteran reported he had not obtained assistance for his alcohol abuse yet, which was a condition for his return to the program, but he stated he quit without help. The counselor advised him that he would need to complete a substance abuse treatment program with documentation that he had remained sober for at least 60 days to return to the vocational rehabilitation program. In January 2009, the Veteran began participating in a VA Return-from-Relapse group related to his alcohol and cannabis abuse. In a September 2009 report, a private psychiatrist, M. Cesta, M.D., indicated he was asked to review the medical record and personally interview the Veteran. (It is unclear to the Board whether the interview was conducted via telephone, video conference, or in-person; the evidence reflects that Dr. Cesta lives in Minnesota and the Veteran lives in Alabama). Dr. Cesta believed there was “clear evidence of severe and disabling symptoms since the latter years of [the Veteran’s] active duty service,” which “led to a significant substance use disorder, and violent behavior leading to incarceration for manslaughter in the past.” Dr. Cesta also believed that although the Veteran had “received other diagnoses, these are all either erroneous due to the VA’s lack of correct information directly associated with the Veteran’s PTSD, or they have failed to address the direct connection to his primary diagnosis of PTSD.” Dr. Cesta outlined his review of the evidence and concluded that it was “quite clear from the medical documentation, the statements from multiple attending providers, and the majority of clinical conclusions drawn that this Veteran has extremely severe symptoms of PTSD dating from his third enlistment in the late 1970s and early 1980s. It is also very clear from this documentation that he had a variety of comorbid clinical conditions, most notably substance use disorders.” The diagnosis was chronic PTSD with delayed onset, alcohol dependence, and polysubstance abuse. Dr. Cesta assigned a GAF score of 25 based on the Veteran’s PTSD alone, “including his comorbid diagnosis of alcohol dependence and other diagnoses which are a component of his PTSD.” Dr. Cesta opined that “although [the Veteran] has a variety of physical disabilities, including the…head injury, his PTSD has been extremely severe since his active duty service in the late 1970s and early 1980s, and he has been clearly unemployable since at least 2000 (with severe and disabling symptoms prior to that date).” In December 2013, a VA psychiatrist reviewed the Veteran’s claims file and provided a medical opinion addressing the timing of a causal nexus between the Veteran’s PTSD symptoms and his military stressors involving Operation Eagle Pull and Operation Frequent Wind. In doing so, the VA psychiatrist observed that Dr. Cesta’s opinion report included “strong, definitive conclusions that there was ‘no question’ that the Veteran has ‘severe PTSD’ and that there was ‘no question that this Veteran has suffered from severe disease leading to complete disability’” since his discharge from service. The VA psychiatrist “question[ed] the validity of this examination.” The VA psychiatrist explained that contrary to the “very strongly-worded,” “definitive conclusions” reached by Dr. Cesta “as if this is a very straightforward case,” he found the evidence to be “very complex” as “evidenced by the multiple conflicting factors and different conclusions that have [been] reached by numerous experienced examiners and evaluators over the years.” For example, while Dr. Cesta opined that the Veteran’s symptoms were “clearly associated with his active duty service in Vietnam,” the VA examiner noted he appeared to reach that conclusion “without apparent consideration for the impact of the Veteran’s other acknowledged stressors or his other significant psychiatric issues.” Regarding the Veteran’s substance abuse, the VA psychiatrist detailed that it had been his “experience with treating substance abuse patients for nearly 20 years that the causative factors contributing to substance abuse are generally multifactorial. Although traumatic experiences can certainly play a role, other factors are well known to contribute, including biological factors, family background, early life experiences, and medical issues,” among others. Therefore, the VA psychiatrist explained he “would hesitate to retrospectively conclude that this Veteran’s substance abuse issues were clearly a means of coping with PTSD” because “[t]ypically, the etiology of substance abuse is simply not that straightforward to definitively understand.” Similarly, while Dr. Cesta concluded the Veteran’s PTSD was the cause of the Veteran having committed murder in 1993, the VA psychiatrist again explained he would be “reluctant to retrospectively conclude that PTSD was the cause of the murder.” The VA psychiatrist reasoned that [a]lthough this Veteran was diagnosed with PTSD on several occasions in the 1990s and early 2000s, his PTSD symptoms at that time were generally described as being secondary to other stressors not eligible for consideration for service connection (service in Beirut, having killed his common law wife, or having been assaulted and beaten). Also during this time frame, the Veteran was prominently diagnosed with active substance abuse, depression, a personality disorder, and a head injury. Hence, I believe that many of the longstanding psychiatric and adjustment issues that this Veteran has chronically experienced have likely been related to multiple issues including traumas not eligible for consideration for service connection, chronic substance abuse, and personality disorder, and not exclusively to PTSD symptoms related to service in Vietnam. In a June 2015 report, Dr. Cesta indicated he had reviewed the medical record, service record, and ancillary information a second time and opined that the Veteran “had PTSD from 1977 going forward.” He stated the Veteran’s “PTSD would be considered of delayed onset as his last tour of duty in Vietnam was approximately one year before the full development of his PTSD symptoms.” Dr. Cesta acknowledged the Veteran has a “complicated clinical course that had also included a traumatic brain injury and a substance use disorder.” However, Dr. Cesta believed the Veteran’s “symptoms of PTSD were overt and present before Beirut in 1983, before the death of his common-law wife in 1993, and before any traumatic brain injury.” As a result, Dr. Cesta concluded the “simple chronology of this patient’s clinical condition does not afford [the December 2013 VA psychiatrist’s] statements to be valid.” Having considered the medical and lay evidence of record, the Board finds that an initial rating of 70 percent is warranted for the Veteran’s service-connected PTSD with alcohol and substance abuse. As explained above, the record shows that the Veteran has a complex history of multiple psychiatric and head injury disorders other than his service-connected PTSD with alcohol and substance abuse; however, where the record does not clearly indicate which symptoms are part and parcel of the service-connected disability versus the nonservice-connected disability, the Board will consider all symptoms in rating the service-connected disability. For the time periods from December 23, 1997 through July 26, 2006 and from November 1, 2006 through August 27, 2009, the Veteran’s psychiatric disability resulted in occupational and social impairment in most areas. He has displayed symptoms such as irritable, dysthymic mood with episodes of violence or angry outbursts; flat, constricted, or anxious affect; mild memory impairment; limited insight and judgment; impaired concentration; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. Subjectively, his PTSD has been manifested by mood lability with angry outbursts and a propensity for violence; sleep disturbance; memory impairment; and some distressing dreams. The Board finds these manifestations more nearly approximate the criteria for a 70 percent rating. However, a higher, 100 percent rating is not warranted for either period because the Veteran’s PTSD has not been manifested by “particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (describing when a veteran may qualify for a given disability rating under [38 C.F.R.] § 4.130). For example, a 100 percent rating contemplates symptoms such as a persistent danger of hurting self or others. During the two relevant time periods in this appeal, which span a period of 12 years, the Veteran endorsed suicidal ideation without intent or plan in November 2001 and occasional auditory hallucinations, each related to the non-military stressor of killing his common-law wife. Because his suicidal ideation was clearly in relation to a non-military stressor, it is insufficient to support a higher rating. Moreover, the evidence of record shows the Veteran has not been a persistent danger to himself. Considering his behavior toward others, the Veteran generally demonstrated intact or “good” impulse control. However, in September 2000 he assaulted his girlfriend’s son, in July 2001 he put his arm through a window, and in September 2002 he was asked to leave a VA cafeteria after a rage episode. The Board finds these symptoms and behaviors more nearly approximate the criteria for a 70 percent rating because they did not occur with sufficient frequency to meet the criteria for a 100 percent rating. Considering his cognitive function, although he has had some impairment in memory and concentration, particularly after the November 2000 assault involving head trauma, the evidence of record documents he has been oriented to person, time, and place; he can recall his own name and former occupation; and he has been able to communicate his thoughts and feelings to others. These findings do not warrant a higher, 100 percent rating. Finally, while the Veteran sometimes endorsed feeling depressed and was observed to appear depressed at times, his depression symptoms have not been shown to cause intermittent inability to perform activities of daily living or to be near-continuous, affecting the ability to function independently, appropriately, and effectively. The evidence demonstrates the Veteran’s depression has not been that frequent or severe. Instead, his VA treatment records document he participated in an incentive therapy program for a number of years, working as a patient escort where he reported to the job assignment on time, maintained good hygiene and appearance, and got along well with staff and peers. Notably, although the Veteran endorsed suicidal ideation in November 2001, the Board finds this single instance of this symptom insufficient to warrant a 100 percent rating because the Veteran himself attributed this symptom to the experience of killing his common-law wife in 1993. Regardless, the Veteran’s single episode of suicidal ideation has not been shown to result in social or occupational impairment beyond the criteria for a 70 percent rating. The Board also notes that the November 2005 VA examiner accurately pointed out that during the period of several years that the Veteran decreased or ceased his alcohol consumption, the treatment records documented a corresponding decrease in mood and behavioral disturbance and improved sleep. In other words, the Veteran appeared to experience some degree of improvement in psychiatric symptoms during the time that he decreased his alcohol consumption. The Board also finds that the GAF scores assigned during the periods from December 23, 1997 through July 26, 2006 and from November 1, 2006 through August 27, 2009, which ranged from 45 to 62, do not provide a basis for a rating in excess of 70 percent. Again, GAF scores ranging from 45 to 62 denote symptoms and impairment ranging from serious to mild. The Board finds the majority of the assigned scores, which indicate moderate to serious symptoms or impairment, are consistent with the severity, frequency, and duration of the Veteran’s PTSD symptoms as noted in the contemporaneous clinical evidence of record. The Board considered the opinions by Dr. Cesta that the Veteran’s delayed-onset PTSD has been “extremely severe” since 1977. However, in considering the proper disability rating during the applicable time periods, the Board finds the contemporaneous treatment records in which numerous psychiatrists, psychologists, and other medical professionals observed and interacted with the Veteran face-to-face more persuasive than Dr. Cesta’s retrospective opinions, which were based on a review of the evidence provided to him and an interview with the Veteran in September 2009. In summary, the Board finds that a rating higher than 70 percent is not warranted for the Veteran’s PTSD at any time from December 23, 1997 through July 26, 2006 and from November 1, 2006 through August 27, 2009. The Board has considered staged ratings under Fenderson v. West, 12 Vet. App. 119 (1999), but concludes that they are not warranted because as explained above, the medical and lay evidence of record did not support a higher rating than already assigned. 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 for a higher rating than that granted herein, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to a TDIU due to service-connected PTSD prior to August 28, 2009 The Veteran contends that his service-connected PTSD precludes him from obtaining or retaining substantially gainful employment consistent with his occupational history and education. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities; provided that, if there is only one such disability, this disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a); see also 38 C.F.R. §§ 3.340, 3.341. Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Thus, the Board may not consider the effects of the Veteran’s nonservice-connected disabilities on his ability to function. As granted herein, the Veteran’s service-connected PTSD has been rated 70 percent disabling effective December 23, 1997, notwithstanding periods during which a temporary total rating was in effect. Thus, the Veteran meets the threshold schedular criteria for entitlement to a TDIU pursuant to 38 C.F.R. 4.16(a). The question for the Board is whether the Veteran is unable to secure or follow a substantially gainful occupation consistent with his education and occupational history as a result of his service-connected PTSD. In his September 2009 formal application for a TDIU, the Veteran reported he had not worked since 1989, but did not leave his last job due to his PTSD disability. He indicated he completed one year of college and had not participated in other education or training either before or after he became too disabled to work. In a December 1991 claim for nonservice-connected pension benefits, the Veteran reported that he last worked in November 1992 [sic] as a truck driver for Milton Construction Company, holding that position for 11 months. He identified the disabilities that affected his ability to work as “stomach removed because ulcer” in December 1991 and high blood pressure since October 1992 [sic]. During a March 1992 VA examination, he stated he had worked as a semi-truck driver, but had been unable to perform his duties due to stomach discomfort from recurrent peptic ulcer disease with recurrent gastrointestinal bleeding and abdominal adhesions. In a December 1997 claim for nonservice-connected pension benefits, the Veteran stated he had worked for Milton Construction Company for 96 months (8 years) and last worked in November 1989. He reported completing two years of college. In September 2001, the Veteran presented for a vocational rehabilitation consultation. The psychologist concluded based on a review of medical records and the present evaluation that the severity of the Veteran’s physical and psychiatric symptoms, including from PTSD, impair him in being able to meet the demands of work on a sustained basis in a competitive work environment. While the Veteran did not qualify for vocational rehabilitation, he underwent further screening and was accepted to the incentive therapy program where he worked for a number of years in a VA medical center as a patient escort. The Board observes that the Veteran’s work in the VA incentive therapy program occurred in a “protected environment” and, therefore, is considered “marginal employment.” See 38 C.F.R. § 4.16(a). The Board has considered the entire record, including the Veteran’s educational background and his occupational history as a semi-truck driver, and finds that the evidence is at least evenly balanced as to whether the limitations due to his service-connected PTSD preclude him from obtaining or following a substantially gainful occupation. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (“[A]pplicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner”). On the one hand, the evidence suggests that the Veteran’s employment difficulties may be related to his legal history including periods of incarceration, alcohol and cocaine consumption, and other nonservice-connected disabilities such as gastrointestinal disorders and traumatic brain injury with a seizure disorder. On the other hand, the evidence indicates the Veteran has experienced difficulty getting along with others manifested by significant irritability with periods of violence, limited insight and judgment, and difficulty in adapting to stressful circumstances. The Board reiterates that when it is not possible to separate the effects of a nonservice-connected disorder from those of a service-connected disorder, reasonable doubt should be resolved in the claimant’s favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Therefore, to the extent that any VA examiner or the Board is unable to discern whether the Veteran’s PTSD symptoms or nonservice-connected disorders contribute to the Veteran’s inability to obtain or maintain a substantially gainful occupation, the Board resolves reasonable doubt and attributes the Veteran’s occupational impairment to PTSD. As the reasonable doubt created by the relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to a TDIU is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel