Citation Nr: 18144936 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 10-34 326 DATE: October 25, 2018 ORDER Entitlement to service connection for a thoracolumbar spine disorder, diagnosed as an old compression fracture of T11 and T12 (claimed as a right-sided low back disorder and also as secondary to service-connected posttraumatic stress disorder (PTSD)), is granted. Entitlement to service connection for a right knee/thigh disorder, diagnosed as right thigh numbness/nerve irritation, is granted. Entitlement to an initial evaluation in excess of 50 percent for PTSD prior to October 1, 2015, is denied. An initial evaluation of 70 percent, but no higher, for PTSD from October 1, 2015, to February 10, 2016, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial evaluation in excess of 70 percent for PTSD on or after February 11, 2016, is denied. FINDINGS OF FACT 1. The Veteran’s old compression fracture of T11 and T12 is the result of an in-service ski jumping injury. 2. The Veteran’s right thigh numbness/nerve irritation is the result of an in-service ski jumping injury. 3. Prior to October 1, 2015, the Veteran’s PTSD was productive of occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas. 4. Since October 1, 2015, the Veteran’s PTSD has been productive of occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, a thoracolumbar spine disorder, diagnosed as an old compression fracture of T11 and T12, was incurred in active service. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. Resolving reasonable doubt in favor of the Veteran, a right knee/thigh disorder, diagnosed as right thigh numbness/nerve irritation, was incurred in active service. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. Prior to October 1, 2015, the criteria for an initial evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2017). 4. From October 1, 2015, to February 10, 2016, the criteria for an initial 70 percent evaluation, but no higher, for PTSD have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2017). 5. Since February 11, 2016, the criteria for an initial evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1944 to August 1946. This case comes before the Board of Veterans’ Appeals (Board) on appeal from October 2008 and April 2010 rating decisions of the Department of Veterans Affairs (VA). A videoconference hearing was held before the undersigned Veterans Law Judge in October 2015. A transcript of the hearing is of record. The undersigned Veterans Law Judge held the record open for a 30-day period following the hearing to allow for the submission of additional evidence. Thereafter, the Veteran submitted additional evidence that was considered by the agency of original jurisdiction (AOJ) in the March 2016 supplemental statement of the case. In a November 2015 decision, the Board reopened the low back disorder claim and remanded the case for further development. In February 2010 and July 2010 rating decisions, the AOJ increased the evaluation for PTSD. While the case was in remand status, the AOJ increased the evaluation for PTSD to 70 percent in a March 2016 rating decision, effective from February 11, 2016. Because these evaluations do not represent the highest possible benefit, the issue is in appellate status and has been recharacterized as stated above. AB v. Brown, 6 Vet. App. 35 (1993). In addition, the Veteran filed a claim for a total disability rating based on individual unemployability due to service-connected disability (TDIU) in April 2016. If a claimant or the record reasonably raises the question of whether a veteran is unemployable due to the disability for which an increased evaluation is sought, then part and parcel to that claim for an increased evaluation is whether TDIU as a result of that disability is warranted. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, however, the AOJ granted entitlement to TDIU in a May 2016 rating decision, effective from February 11, 2016. The Veteran did not express disagreement with that decision. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). The Board again remanded the case for further development in July 2016. That development was completed, and the case was returned to the Board for appellate review. The Board also requested an advisory medical opinion from the Veterans Health Administration (VHA) in August 2017 for the thoracolumbar spine and right knee claims. The Veteran and his representative were sent a copy of the opinion and given 60 days to submit further evidence or argument. See 38 C.F.R. §§ 20.901, 20.903. In a February 2018 response, the Veteran indicated that he had no further argument or evidence to submit and requested that the Board proceed with adjudication of the appeal. The Board requested an additional VHA opinion in May 2018, as well as a clarifying VHA opinion in August 2018 to address remaining medical questions. The Board has recharacterized the right knee disorder claim to include the right thigh based on the 2018 VHA physician’s opinions and the other medical and lay evidence of record indicating that the Veteran’s problems have been in his thigh area down to his knee. Given the fully favorable outcome as to the thoracolumbar spine and right knee/thigh claims, there is no prejudice to the Veteran in the Board deciding the issues without sending him a copy of the additional opinions. Law and Analysis Initially, the Board finds that VA’s duty to assist has been met as to obtaining outstanding treatment records. In response to the Board’s November 2015 remand, the AOJ sent a letter to the Veteran the following month to identify and provide authorization forms for any non-VA health care providers. The Veteran responded in January 2016 that he had received VA mental health treatment. The AOJ obtained outstanding and updated VA treatment records based on the Veteran’s report and in response to the Board’s subsequent July 2016 remand. The Board also finds that VA’s duty to assist has been met as to obtaining a VA examination or medical opinion. The Board requested a new VA examination in the November 2015 remand based on evidence suggesting that the Veteran’s PTSD had increased in severity since the most recent VA examination. The Veteran was provided an adequate VA examination in February 2016 that fully address the rating criteria that are relevant to rating the disability in this case. There is also no objective evidence indicating that there has been a material change in the severity of the Veteran’s service-connected PTSD since he was last examined. Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist for the PTSD claim (the claim that has not been granted in full). See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection – Thoracolumbar Spine and Right Knee/Thigh Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for an old compression fracture of T11 and T12 (thoracolumbar spine disorder) and right thigh numbness/nerve irritation (right knee/thigh disorder). The Veteran has essentially contended that his current back and right knee problems are the result of a progressive process following an initial injury during his military service. See, e.g., October 2015 Bd. Hrg. Tr. at 5-7 and January 2016 written statement. He has also contended that his service-connected PTSD has caused his current back problems, as he fell out of bed when having nightmares. See October 2015 and December 2015 VA treatment records (December 2015 Ann Arbor VA Medical Center (VAMC) treatment VBMS entry). The Veteran’s service treatment records show that he was found to have no musculoskeletal defects at the time of the October 1944 entrance examination. The August 1946 separation examination shows that he twisted his back right side in March 1946. His service records also indicate that his duties included serving as an entertainment specialist with the United States Army Ski Team, competing in ski tournaments and ski jumping. The Board finds that the Veteran’s competent and credible recollection of his in-service ski jumping injury is consistent with the circumstances of his service and constitutes an in-service event. See also, e.g., VA treatment records from October 2009 and May 2010 (Veteran reported during mental health treatment that he worked as long as he could without complaining about getting hurt during service). The Board also finds that the Veteran has current thoracolumbar spine and right knee/thigh diagnoses that are related to the in-service ski jumping injury. See, e.g., August 2009 MRI report; October 2009 VA examination report (diagnoses). In a written statement received in December 2009, the Veteran’s treatment provider (Dr. J.S.) noted his report of right low back pain and right leg pain to the knee, as well as his in-service history of ski jumping. He indicated that the presenting problem at that appointment was suspect early lumbar stenosis and determined that it was just as likely as not that the Veteran’s original in-service skiing injuries contributed to or initiated his current complaint. In a May 2011 written statement, Dr. J.S. indicated that the Veteran had suffered low back pain and right leg pain since an in-service ski jumping accident and that it was more likely than not that his pain and difficulty working through the years were directly related to that accident. The Board acknowledges these opinions from the Veteran’s VA treatment provider in support of these claims; however, the opinions are inadequate because they do not contain a complete rationale. The Veteran was afforded a VA examination in October 2009, and a clarifying opinion was obtained in March 2010. The October 2009/March 2010 VA examiner determined that the Veteran’s current right knee (degenerative joint disease) and back (degenerative joint disease and degenerative disc disease of the thoracic and lumbosacral spine with radiculopathy of the right lower extremity) disorders were less likely as not caused by his in-service ski injury; however, the examiner did not address whether repetitive jumping may have caused the current disorders. Thereafter, the VA treatment records show that the Veteran reported having a bad dream and falling out of bed in October 2015. He was diagnosed with an acute lumbar strain; the results of a November 2015 MRI in the course of VA treatment are of record. The VA treatment records also provide the results of various x-ray and MRI reports of the back prior to this incident. See, e.g., August 2009 thoracolumbar spine MRI report (including impression of mild decrease in anterior height of the T11 and T12 vertebral bodies old posttraumatic or congenital); October 2009 thoracic spine x-ray report (including finding of moderate anterior wedging deformities of multiple thoracic vertebrae of indeterminate age); April 2010 lumbosacral spine x-ray (impression of mild diffuse degenerative disc disease); December 2014 chest x-ray report (impression including mild degenerative and atherosclerotic changes and slight anterior wedging of several mid to lower thoracic vertebral bodies; old healed fracture of the posterior lateral aspect of the right sixth rib) (December 2015 Ann Arbor VAMC and December 2016 Iron Mountain VAMC treatment VBMS entries). The Veteran was afforded another VA examination in February 2016. The VA examiner determined that it was less likely than not that the Veteran’s current right knee (degenerative arthritis) and low back (lumbosacral spine degenerative arthritis and degenerative disc disease with associated lumbar stenosis) disorders were incurred in or caused by service, including any injury or the cumulative effect of repetitive skiing and ski jumping therein. In so finding, the examiner indicated that the Veteran had a normal separation examination without any back or right knee condition and noted the fact that there were no immediate post-service medical records (civilian or military) documenting any back or right knee condition. The examiner further explained that the findings were related to the natural progression of degenerative arthritis, and the degenerative disc disease of lumbar spine with associated lumbar stenosis was related to the inherited biology and lifelong stress on the Veteran’s back and likely not related to a specific injury or event. Thereafter, the Board requested an additional VA medical opinion because it was unclear if the finding on the November 2015 MRI report of an acute to subacute superior T12 compression fracture (reviewed as part of the February 2016 VA examination) was part of the thoracolumbar spine diagnosis already provided or a separately diagnosable disorder. It was also unclear if the examiner considered the complete history of the development of the right knee disorder, to include the Veteran’s reports as to intermittent but ongoing symptoms since service. In addition, an opinion addressing the Veteran’s additional causal theory that his service-connected PTSD has caused him current back problems because he fell out of bed when having nightmares was necessary. In a January 2017 clarifying opinion, the February 2016 VA examiner determined that the acute to subacute superior T12 compression fracture on the November 2015 MRI report was a different medical condition of the spine and not part of the thoracolumbar spine degenerative arthritis diagnosis. In so finding, the examiner explained that the two conditions were distinct and separate without any pathophysiological or biomechanical relations. The examiner acknowledged the notation on the separation examination of the Veteran twisting his back right side in March 1946, but determined that the condition resolved, as there were no further sequelae, with a normal separation examination. The examiner explained that degenerative arthritis of the lumbar spine or knees usually presents over many years with a slow progression. The examiner further explained that the disorder is usually caused by inherited biology and lifelong stress on the back and knees and likely not related to a specific injury or event. Although the February 2016/January 2017 examiner adequately addressed questions related to the current right knee and back disorders and provided adequate opinions for the degenerative diseases on a direct basis, she did not provide an etiology opinion on the T12 compression fracture following the finding that it was a separate disorder from the thoracolumbar spine degenerative arthritis. The examiner also did not address the Veteran’s contention regarding his back problems and the fall from his service-connected PTSD. In summary, the above medical opinions were not adequate to decide the case for the reasons outlined above. See also Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993); Black v. Brown, 5 Vet. App. 177, 180 (1993) (an opinion based on an inaccurate (or unsubstantiated) factual premise has limited, if any, probative value) and Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The Board subsequently requested VHA opinions in August 2017, May 2018, and August 2018 to address the remaining medical questions based on consideration of the complete history of the development of the thoracolumbar spine and right knee/thigh disorders. The August 2017 VHA physician determined that it was more likely than not that the Veteran’s thoracolumbar spine and bilateral knee degenerative disease and pain in those regions was not caused by his military service, including multiple ski jumps, repetitive skiing, and/or a fall. In so finding, the examiner expressed agreement with the February 2016/January 2017 VA examiner that any strain to the back would have resolved long ago. The VHA physician noted that the Veteran presented with evidence of widespread degenerative changes in 2009, including of the back and knees, which was typical of his stage in life. He also indicated that the MRI report from 2009 reflected a mild decrease in anterior height at T11 and T12 that had undetermined significance (old posttraumatic or congenital were suggested possible etiologies), but that the related findings on the MRI suggested widespread degenerative changes in the lumbar spine which would not likely be traumatic based on the medical history and imaging report reviewed. In addition, he noted that mild to moderate degenerative joint disease of both knees (not just the right knee) was noted during that visit. In addition, the VHA physician explained that the Veteran’s degenerative arthritis alone would explain his symptoms with a reasonable degree of medical probability. He further explained that mild anterior loss of disc height reported on x-ray or MRI is a non-specific finding and does not confirm or even support a traumatic compression fracture has occurred; acute compression fractures can be symptomatic for a long time and often take up to 6 to 12 months to return to normal activities of living, or at least to baseline. In this case, the VHA physician noted, there was no indication based on the Veteran’s records that a significant injury such as that occurred while he was on active duty. Rather, a normal examination at separation was found without evidence of disability, contrary to the notion that a fracture occurred while skiing. The Board requested an additional VHA opinion to address the findings referable to the posterior lateral aspect of the right sixth rib. The May 2018/August 2018 VHA physician, on the other hand, determined that it was more likely than not that the Veteran has an old compression fracture at T11 and T12 and right thigh numbness/nerve irritation that were the result of an in-service ski jumping injury. In so finding, the VHA physician indicated in the initial opinion that the history provided by the Veteran in the October 2009 VA examination was consistent with a small compressing fracture around T12 with right thigh numbness and possible rib fractures and that, although it was hard to imagine doing more jumping with these problems, it would have been possible for a highly motivated person. He agreed that there were not any medical records to substantiate that information, but also noted that it would not be unusual to have limited medical records in the post-war environment in Germany. The VHA physician noted the numerous subsequent x-rays showing evidence of a small compression of T11 and T12, as well as old rib fractures. He explained that the term acute to subacute on the November 2015 MRI showing an acute to subacute superior T12 compression after the Veteran’s fall out of bed (a new compression) suggested that there was some bone edema seen, suggesting at least a little more compression of the vertebra over what it had been with the old compression, causing more pain. He also noted that there was limited documentation for the right knee, but even so, the right knee/thigh problem was related to the in-service fall. In his second opinion, the VHA physician confirmed that the Veteran had an old compression fracture of T11 and T12, as well as ongoing right thigh pain that was from irritation of a nerve from that area, both related to the in-service injury. He also confirmed that the acute to subacute finding indicated that the T12 was compressed a little more at that time, which he considered a new problem, as the old compression fracture had plenty of time to heal. The Board finds that the August 2017 and May 2018/August 2018 VHA opinions are highly probative on these matters, as they are based on a review of the claims file and are supported by rationale. Nieves-Rodriguez v. Peake, supra. The Veteran’s report and subsequent neurological findings (referable to the hamstring and quadriceps muscles and decreased sensation to the right lower leg) on the October 2009 VA examination report also support the May 2018/August 2018 VHA physician’s determination as to the neurological problem with the right knee/thigh area. Based on the foregoing, there is a reasonable doubt as to whether the Veteran has thoracolumbar spine and right knee/thigh disorders related to his in-service ski jumping injury. Resolving reasonable doubt in favor of the Veteran, the Board concludes that service connection is warranted for an old compression fracture of T11 and T12 and right thigh numbness/nerve irritation. Increased Evaluation – PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where VA’s adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Fenderson, 12 Vet. App. at 126-27. In this case, the now-assigned uniform staged evaluations, but no higher, are warranted based on the evidence. The Veteran is currently assigned a 50 percent evaluation for his service-connected PTSD prior to February 11, 2016, and a 70 percent evaluation thereafter pursuant to 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), Diagnostic Code 9411. Effective August 4, 2014, VA amended the portion of the rating schedule dealing with mental disorders and its adjudication regulations to incorporate the Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) rather than the Fourth Edition (DSM-IV). See 79 Fed. Reg. 45093 (Aug. 4, 2014) and 80 Fed. Reg. 14,308 (March 19, 2015) (adopting interim final rule as final). Given that the Veteran perfected an appeal as to this issue several years prior to the regulation change, the Board has considered both versions of the DSM in this decision. The Board also notes that the most recent VA examination was conducted using the DSM-5. Under the General Rating Formula, a 50 percent evaluation is warranted 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 in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are not meant to be 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. If the evidence shows that a veteran has symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002); Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). In addition, evaluation under § 4.130 is “symptom-driven” and “a veteran may only qualify for a given disability rating under [this criteria] by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Section 4.130 “requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In assessing the degree of psychiatric disability under the DSM-IV, Global Assessment of Functioning (GAF) scores are for consideration and reflect the “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.” Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the DSM-IV). However, the GAF score assigned in a case, like an examiner’s assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that an initial evaluation in excess of 50 percent is not warranted prior to October 1, 2015, and an initial evaluation in excess of 70 percent thereafter is not warranted for PTSD. The Board also concludes that an initial evaluation of 70 percent is warranted from October 1, 2015, to February 10, 2016. The Veteran sought VA mental health treatment in November 2008 after previously receiving mental health treatment several years prior. During the consultation, he reported that he was having more difficulty with nightmares, bringing him back to his time in World War II and affecting his sleep. On mental status evaluation, he was fully oriented, his memory was intact, and his thought content was within normal range. He was well-nourished with good hygiene and grooming, his mood was within normal range, and his attitude was cooperative, polite, and very pleasant. He also denied feeling as though he was a burden to anyone, felt a sense of belonging with significant others, was especially close to his two dogs (which kept him busy), and he declined needing any immediate attention or referral for suicidal or homicidal issues. The treatment provider noted that the Veteran had experienced problems with his primary support group, as his long-term significant other (O.) passed away a year prior, which was very difficult for him, and that he was also having some financial problems and poor sleep due to nightmares. The Veteran requested and was referred for VA mental health treatment as a result of that consultation, and he began appointments with VA treatment provider M.M., LMSW, that same month. During the intake appointment, the Veteran again reported experiencing increased difficulty with more nightmares and memories of his war experiences. On mental status evaluation, the Veteran was appropriately and casually attired; exhibited good personal hygiene; presented no psychomotor agitation or retardation, abnormalities, or remarkable mannerisms; and was cooperative, pleasant, help seeking, and easy to build a rapport with. He sustained good eye contact and was easily engaged with the interview. His mood appeared dysphoric at times, but it was generally euthymic, and his affect was congruent with the discussion topic. The Veteran was alert; oriented to person, place, time, and situation; and his speech was normal in terms of tone, volume, and prosody. He gave a history that appeared orderly and consistent in terms of dating events. His remote, recent, and immediate memory appeared grossly intact, and his thought content was void of any loose associations, tangential, or fixations. His thought process was logical and goal directed. In addition, the Veteran’s perception was appropriate, his intelligence appeared to be normal, and his insight appeared to be good. The Veteran reported that his last relationship had lasted for 15 years and that his significant other died the year prior. He did not have much contact with his children from prior marriages due to their mothers’ remarrying and his desire to not interfere, but he reported that he got along with his children. He also reported that he lived by himself in a rental unit, had a few friends, went to his veterans service organization, and attended church. For leisure and recreation, the Veteran hunted and fished, and it was noted that his personal strengths included having good physical health for his age, having some supportive friends, and being cooperative and motivated for treatment. For the high-risk factors assessment, the Veteran did not express any suicidal or homicidal thoughts or impulses and denied an intent to harm himself. He had increased depression and felt like he did not want to go on after the death of his significant other, but he denied any plan or intention, denied any history of suicidal behavior, and denied any intent of violence towards others. In a mental health treatment plan note from the following week, M.M. noted that the Veteran’s prognosis was good, considering his motivation and insight. See VA treatment records from November 13 and November 20, 2008. Thereafter, the Veteran had regular appointments with M.M. in the fall, spring, and summer months from November 2008 to November 2012, when he was located in Michigan; he would spend the winters with his step daughter (O.’s daughter) in Florida. He discontinued his treatment when M.M. transferred to a different position, as he preferred not to start over with another treatment provider, but the Veteran checked in periodically on an informal basis. See, e.g., VA treatment records from December 2008 (Veteran called to wish M.M. a Merry Christmas and to report that he would be at daughter’s for next couple of months); October 2015 (treatment history). Notably, the VA treatment records for the Veteran’s mental health treatment from 2008 to 2012 show substantially similar findings as to his mental health presentation and reported symptoms, including an appointment in 2009 with another treatment provider. See July 2009 VA treatment record (also noted judgment good; medication at bedtime for mood and sleep). He did continue to have difficulties with nightmares; he was encouraged to use techniques such as playing the radio and imagery to help him in that regard. See, e.g., VA treatment records from April 2010, September 2010, and November 2011. The Veteran had also been a caretaker of a hunting camp for his friend during that time, living by himself in the middle of a national forest in exchange for a place to live during the warmer months. He reported that the friend needed to sell the camp at one point, but the friend later became less motivated to sell it. See VA treatment records from November 2010, November 2011, and April 2016; see also, e.g., September 2012 VA treatment record (Veteran reported continued work around the camp to get it ready for hunting). An April 2012 VA treatment record shows that M.M. found the Veteran to be clinically stable. The Veteran was also provided VA examinations in May 2008 and November 2009 with the same VA examiner. The May 2008 VA examination report shows that the Veteran reported similar difficulties to those during his VA treatment, including nightmares with sleep difficulty, and his mental health presentation was also similar in many areas, including his orientation, appearance and hygiene, mood, thought process, judgment, and memory. The examiner also noted symptoms such as avoidance behavior, a persistent sense of a foreshortened future, self-isolation, and irritability, and he determined that the severity and duration of the Veteran’s psychiatric symptoms were mild to moderate. The examiner also determined that the Veteran’s PTSD resulted in moderate social impairment. In the November 2009 VA examination report, the examiner noted that there had not been major changes in the Veteran’s daily activities since his last examination; the Veteran continued to spend most of his time isolated, visiting with one or two trusted friends. He also continued to live with his dogs. The examiner further noted that there had been major social function changes, such as the Veteran being more limited due to his physical and emotional conditions. He went out less and participated and relied on counseling more. The Veteran reported being increasingly stressed about his ability to care for himself. The examination report again shows that the Veteran reported similar difficulties to those during his VA treatment, including nightmares with sleep difficulty (both noted to have increased), and his mental health presentation was also similar in many areas, including his orientation, appearance and hygiene, mood, thought process, and memory; his judgment was noted to be impaired. The examiner also noted symptoms, such as avoidance behavior and social isolation, and he determined that the severity and duration of the Veteran’s psychiatric symptoms resulted in moderate to severe impairment in social and emotional functioning. The Veteran also submitted lay statements from his friends and step daughter that reflected his problems with nightmares and physical problems (such as hitting the wall while having a nightmare), having periods of significant depression and mood swings, and withdrawing from others. See written lay statements received in September 2010. Based on the foregoing, the Board finds that the Veteran’s overall disability picture, to include the severity, frequency, and duration of his symptoms, as well as the resulting impairment of social and occupational functioning, is consistent with a 50 percent evaluation prior to October 1, 2015. See also, e.g., May 2009 VA treatment record (Veteran’s objectives included having VA disability increased from 30 percent to at least 50 percent for PTSD). The Veteran had a history of recurring symptoms, including nightmares with sleep disturbance and avoidance behavior, as set forth above. The VA examiner determined in the May 2008 VA examination that the Veteran’s psychiatric symptoms were mild to moderate and that his PTSD resulted in moderate social impairment. In the November 2009 VA examination report, the VA examiner determined that the severity and duration of the Veteran’s psychiatric symptoms resulted in moderate to severe impairment in social and emotional functioning. The examiner indicated that the Veteran was retired, but it does not appear that he fully contemplated the Veteran’s ability to work as the caretaker of a hunting camp during this time period and the fact that he lived alone there in exchange for housing (i.e., rather than solely as a way to isolate himself from others). Indeed, the VA treatment records reflect a level of social functioning that is greater than that in the VA examination reports. For example, the VA examination reports show that the Veteran had no contact with any of his six children; however, the VA treatment records indicated that the Veteran reported having gotten along with his children, but that he had decided to not interfere when his former spouses got remarried. In addition, the Veteran had a good relationship with his stepdaughter and looked forward to visiting his family in Florida in the winters (where the stepdaughter lived), an aspect that did not appear to be address during the VA examinations. The VA examiner did note review of part of the claims file, but it does not appear that he reviewed the VA treatment records for the sessions with M.M. See, e.g., VA treatment records from November 13, 2008 (noted history with children); July 21, 2009 (Veteran reported socializing regularly with a friend); September 29, 2009 (Veteran reported looking forward to spending the winter with family); May 2010 (Veteran reported good functioning, attended to own activities of daily living; M.M. noted social functioning unimpaired, spent time at veterans service organization and with friends and winters with step daughter); October 2010 (noted Veteran had positive social supports). The Board finds that the consistent reports and findings in the VA treatment records as to the Veteran’s social functioning to be the most probative evidence on the matter. M.M. met with the Veteran on a regular basis during this time period, and the Veteran routinely shared his concerns with him. The Board does note that the record shows that the Veteran had symptoms of the 70 percent criteria, including panic attacks, depressive symptoms, and suicidal ideation during this portion of the appeal period. However, the record does not suggest that he had panic attacks or depression that were near-continuous in nature, affecting the ability to function independently, appropriately and effectively. See, e.g., November 2009 VA examination report (reported anxiety with occasional panic attacks when he thought about having to face a future in a nursing home). Regarding suicidal ideation, the VA examination reports indicate that the Veteran had this symptomatology without plan or intent. The VA treatment records routinely show that the Veteran denied any suicidal thoughts or impulses and that he had a low (some passive suicidal thoughts that are sporadic with low intensity and duration; strong protective barriers in place) or minimal risk level when evaluated by M.M. See, e.g., VA treatment records from November 2008, August 2009, October 2010, May 2011, and November 2012. In other words, the Board finds that the record does not demonstrate that the Veteran’s overall disability picture is consistent with a 70 percent evaluation for this portion of the appeal period, to include consideration of the Veteran and other lay statements, the VA treatment records, and the VA examination reports. The Veteran did not demonstrate a level of impairment consistent with the 70 percent criteria, nor did his symptoms cause occupational and social impairment with deficiencies in most areas, to include in areas referenced by the 70 percent criteria. Mauerhan, supra, Vazquez-Claudio, supra. The Board acknowledges the GAF scores of 49 and 55 (VA examinations) and 60 and 65 (VA treatment) that were recorded during this portion of the appeal period. A GAF score between 41 and 50 reflects 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). A GAF score between 51 and 60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score between 61 and 70 reflects 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. In this case, the Veteran’s symptoms themselves do not reflect a level of impairment that is indicative of the lowest end of those scores provided by the VA examiner based on the discussion of the Veteran’s social and occupational functioning discussed above. In any event, while considering the GAF scores of record as part of the overall social and occupational functioning picture, the Board finds the narratives contained in the VA treatment records (and the VA examiner’s explanations where consistent with the VA treatment records) to be the most probative evidence of the Veteran’s psychological symptomatology. From October 1, 2015, to February 10, 2016, the Board finds that the Veteran’s overall disability picture, to include the severity, frequency, and duration of his symptoms, as well as the resulting impairment of social and occupational functioning, is more consistent with a 70 percent evaluation. In this regard, in an October 1, 2015, VA appointment with M.M., the Veteran reported that his symptoms had gotten worse, including his depression. He further reported that he “sometimes [felt] like taking a one-way hunting trip” and that, when he was alone, he had more intrusive thoughts more frequently. His nightmares were also more regular. The Veteran reported that he had recently began having a relationship with some of his adult children, but that he was less active and more sedentary recently (unable to be the caretaker of the hunting camp now, unable to do things he had previously enjoyed as a result of his physical problems, specifically his problems related to his in-service ski jumping injury). M.M. indicated that it would appear more likely than not that the increase in the Veteran’s PTSD symptoms were due in part to his decline in functional level and activities secondary to his health, age, and in-service injury; historically, the Veteran was able to suppress a certain level of his PTSD symptoms when he was more active, which he was unable to do at that time. The Veteran and M.M. testified to this increase in symptoms during the Board hearing the following day, such as panic attacks a couple times a week. M.M. noted that the Veteran had typically always been a rather jovial kind of person, looking at the brighter side of things, but indicated that his reports during the October 2015 appointment were new for him. Based on the foregoing, the Board finds that the Veteran’s overall disability picture more nearly approximated occupational and social impairment with deficiencies in most areas since the October 2015 VA treatment record showing that he was no longer able to control some of his PTSD symptoms due to his reduction in physical activity. The February 2016 VA examination report on which the AOJ assigned the 70 percent evaluation also reflects symptomatology consistent with the findings in the October 2015 VA treatment record. Nevertheless, an evaluation in excess of 70 percent is not warranted at any time since October 1, 2015. The Veteran’s overall disability picture, to include the severity, frequency, and duration of his symptoms, as well as the resulting impairment of social and occupational functioning, is consistent with a 70 percent evaluation. For example, the February 2016 VA examination report shows that he had occupational and social impairment with reduced reliability and productivity, along with some symptoms of the 70 percent criteria. The examiner also provided the content of the October 2015 VA appointment, indicating a consistency with the Veteran’s mental health presentation and symptomatology during that entire time. The April 2016 VA treatment records are also consistent with the disability picture in the earlier evidence. Moreover, the Board emphasizes that that a 100 percent disability evaluation requires both total social and occupational impairment. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); cf. Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). Notably, the Veteran has maintained some relationships during this portion of the appeal period. In fact, he has reported having a few friends and indicated that he had resumed a relationship with some of his adult children. See e.g. February 2016 VA examination report. Thus, it cannot be said that he has total social impairment. The Veteran has not demonstrated a level of impairment consistent with the 100 percent criteria, nor have his symptoms caused total occupational and social impairment, to include in areas referenced by the 100 percent criteria. Mauerhan, supra, Vazquez-Claudio, supra. Based on the foregoing, the Board finds that the weight of the evidence is against an evaluation in excess of 50 percent for PTSD prior to October 1, 2015, and in excess of 70 percent thereafter. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied in this regard. Gilbert, 1 Vet. App. 49 (1990). The Board also finds that the evidence supports the assignment of a 70 percent evaluation from October 1, 2015, to February 10, 2016, which is the date on which it was factually ascertainable that the Veteran met the criteria for that evaluation. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Postek, Counsel