Citation Nr: 21042128 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 11-25 928 DATE: July 12, 2021 ORDER A increased 70 percent rating, but no greater, for posttraumatic stress disorder (PTSD) is granted. FINDINGS OF FACT 1. The previous diagnosis of generalized anxiety disorder for the Veteran's service-connected disability was in error. The correct diagnosis for the Veteran's service-connected disability is PTSD. Furthermore, it is not possible to differentiate or distinguish the symptoms of his PTSD from the symptoms of his major depressive disorder and obsessive compulsive personality disorder, as the symptoms of each disability overlap. 2. The Veteran's service-connected PTSD is manifested by psychiatric symptoms causing occupational and social impairment, with deficiencies in most areas, but not total occupational and social impairment. CONCLUSION OF LAW The criteria have been met for an increased 70 percent rating, but no greater, for the Veteran's service-connected PTSD. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.21, 4.125(b), 4.126, 4.130, Diagnostic Code 9411 (formerly Diagnostic Code 9400). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active duty service from June 1988 to June 1992 and from April 1995 to April 2004 in the U.S. Army. He served in the Southwest Asia theater of operations during the Persian Gulf War in the early 1990s. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision issued by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In August 2014, February 2020, and November 2020, the Board remanded the appeal for further development. This case has since been returned to the Board for appellate review, after the AOJ substantially complied with the Board's most recent remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). In the same February 2020 and November 2020 Board decisions, the Board adjudicated various other increased rating issues that were previously on appeal. All of these increased rating issues were denied by the Board. However, the Veteran failed to appeal any of the Board's denials. Thus, at the present time, these particular increased rating issues are no longer on appeal before the Board. I. VA's Duty to Notify and Assist VA's duty to notify under the Veterans Claims Assistance Act of 2000 (VCAA) was satisfied by VA notice letters sent to Veteran, dated in November 2009, June 2010, and December 2010. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159 (2020). These letters advised the Veteran of the information and evidence necessary to substantiate his increased rating claim. With regard to the increased rating issue on appeal, subsequent to the most recent ameliorative November 2020 Board remand, neither the Veteran nor his Agent has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that the Board has an obligation to read filings in a liberal manner, but that obligation 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). II. Increased Rating for 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. 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. The Veteran's service-connected generalized anxiety disorder (GAD) is rated as 30 disabling under Diagnostic Code 9400 (GAD). 38 C.F.R. § 4.71a (2020). This rating has been in effect since November 23, 2009, the day the Veteran's most recent increased rating claim for GAD was received at the AOJ. At the outset, in the recent November 2020 Board remand, the Board requested that a VA examiner clarify what are the Veteran's correct, current psychiatric diagnoses. On this issue, during the appeal, the Veteran has been diagnosed with GAD, PTSD, major depressive disorder, a bipolar disorder, and an obsessive compulsive personality disorder. However, the AOJ has only service-connected the Veteran for his GAD at 30 percent disabling, but not for any of his other psychiatric disabilities. In this regard, VA regulation provides that if the diagnosis of a mental disorder is changed, the rating agency shall determine whether the new diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition. 38 C.F.R. § 4.125(b) (2020). If it is not clear from the available records what the change of diagnosis represents, the rating agency shall return the report to the examiner for a determination. Id. In accordance with the Board's November 2020 remand, the AOJ secured an April 2021 VA PTSD examination by a VA psychologist. The April 2021 VA psychologist assessed that the previous diagnosis of GAD for the Veteran's service-connected mental health disability was "erroneous." The correct diagnosis for the Veteran's service-connected psychiatric disability is PTSD. Furthermore, the VA examiner assessed it was not possible to differentiate or distinguish the symptoms of his service-connected PTSD from the symptoms of his major depressive disorder and obsessive compulsive personality disorder, as the symptoms of each disability overlapped. The VA examiner also commented that the Veteran did not meet the criteria for a current bipolar disorder. In addition, an earlier February 2020 VA addendum opinion by a VA psychiatrist posited that based on a review of the clinical records, it was "at least as likely as not" that the Veteran's obsessive compulsive personality disorder and major depressive disorder were aggravated by his service-connected GAD / PTSD. In this vein, when it is not possible to separate the effects of a service-connected condition from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected condition. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Thus, in rating his now service-connected PTSD disability (formerly identified as GAD), the Board has also attributed the Veteran's psychiatric signs and symptoms from his major depressive disorder and obsessive compulsive personality disorder to his service-connected PTSD disability. Consequently, in the instant Board decision, the Board will consider all the veteran's psychiatric signs and symptoms when determining his level of occupational and social impairment from his psychiatric disorders, without differentiating between his distinct psychiatric disorders. The Veteran believes that his service-connected PTSD is worse than the 30 percent rating assigned since November 23, 2009. He has described frequent depression and anxiety, panic attacks, as well as occasional suicide ideation, previous VA inpatient psychiatric hospitalizations in 2010 and 2011, an inability to establish and maintain effective relationships, difficulty with impulse control and concentration, and difficulty adapting to stressful situations at work. See 38 C.F.R. § 4.130. He also describes experiencing specific PTSD-related symptoms such as hyperarousal, hypervigilance, avoidance of others, flashbacks, hallucinations, and nightmares, among others. He says he last worked as a manager in 2010. He was unable to maintain employment due in part to the severity of his psychiatric symptoms, especially his anger and irritability with other people. He reports having no friends. His only relationships are with family members. He has not stated what exact rating he seeks for his service-connected psychiatric disability. In any event, it is presumed that a veteran continues to disagree with all ratings assigned. See Breniser v. Shinseki, 25 Vet. App. 64, 79 (2011) (citing AB v. Brown, 6 Vet. App. 35, 38 (1993) (noting that a veteran is presumed to be seeking the highest possible rating, unless he expressly indicates otherwise). The Veteran filed an increased rating claim in November 2009. "The relevant temporal focus for adjudicating an increased-rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). Thus, the Board will focus on the evidence of record beginning in November 2008 (one year before the increased rating claim), in adjudicating the increased rating claim at issue. See 38 C.F.R. § 3.400(o)(2); Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board is also cognizant that 38 C.F.R. §§ 4.1 and 4.2 and 4.41 require VA adjudicators to view each disability "in relation to its history" to "accurately reflect the elements of disability present," respectively. See Jones v. Shinseki, 26 Vet. App. 56, 62 (2012); see also Moore v. Shinseki, 555 F.3d 1369, 1373 (Fed. Cir. 2009) (discussing 38 C.F.R. §§ 4.1 and 4.2 and stating that, although the veteran was "only entitled to disability compensation for the period after ... the date he filed his original claim for benefits," VA regulations still require the disability to be "evaluated in light of its whole recorded history"). Therefore, the Board has also considered and reviewed the Veteran's entire history when assigning a disability evaluation for his PTSD disability in the present case. 38 C.F.R. § 4.1. Mental health disorders are evaluated under the general rating formula for mental disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Diagnostic and Statistical Manual (Fifth Edition) (the DSM-5). See 79 Fed. Reg. 45,094 (August 4, 2014). VA adopted as final, without change, this interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14,308 (March 19, 2015). In the present case, the AOJ certified the Veteran's appeal to the Board in March 2012, which is prior to the August 4, 2014 changes. Thus, the earlier version of 38 C.F.R. § 4.125 conforming to the DSM-IV is applicable in the present case. As provided by the General Rating Formula, a 30 percent disability rating is appropriate when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is appropriate 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. Id. A 70 percent rating is in order 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); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order 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; and memory loss for names of close relatives, own occupation, or own name. Id. A veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Rather, the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. Id. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan, 16 Vet. App. at 442. Under the General Rating Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Federal Circuit has held that the General Rating Formula requires not only (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency, or duration (even if unlisted), but also (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The Federal Circuit endorsed an approach whereby the Board would identify the symptoms associated with the service-connected mental health disability, determine whether they are of the kind enumerated in the regulation, and if so, assess whether they result in the level of occupational and social impairment specified by a particular rating. Id. The 70 percent disability rating regulation, in particular, contemplates initial assessment of the symptoms displayed by the veteran, and if they are of the kind enumerated in the regulation, an assessment of whether those symptoms result in occupational and social impairment with deficiencies "in most areas." Id. Reading §§ 4.126 and 4.130 together, it is evident that the "frequency, severity, and duration" of a veteran's symptoms must play an important role in determining his disability level. Id. at 117. In summary, the CAVC and the Federal Circuit have reiterated general principles of rating psychiatric claims according to symptom severity, frequency, and duration, which must be based upon symptoms found in the rating schedule, in addition to symptoms that are not listed. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (2013); Sellers v. Principi, 372 F.3d 1318, 1326-27 (2004); and Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Board recognizes various Global Assessment of Functioning (GAF) scores previously utilized in the DSM-IV, which clinicians have assigned in the present case. The Board can consider the GAF scores in the present case since the DSM-IV applies. Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). A GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. GAF scores may be considered in assigning the appropriate disability rating, but they are not the dispositive element in rating the level of impairment. See Caluza, 7 Vet. App. at 506. Higher GAF scores denote increased overall functioning of the individual. For instance, a score of 41 to 50 illustrates "[s]erious 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)." DSM-IV at 46-47. A score of 51 to 60 represents "[m]oderate 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)." Id. The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev'd on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and duration of his service-connected psychiatric disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (discussing general competency of a Veteran to report psychiatric symptoms). However, the Board can discount lay evidence in its role as factfinder if it weighs the evidence, finds the clinical evidence more probative, and provides an explanation with supporting reasons or bases. English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Upon review, the Board finds the evidence of record is consistent with an increased 70 percent rating for PTSD throughout the entire appeal period. 38 C.F.R. § 4.7. The increased rating claim is granted. That is, the Veteran's service-connected PTSD is manifested by psychiatric symptoms causing occupational and social impairment with deficiencies in most areas, which are indicative of the 70 percent rating criteria. See 38 C.F.R. § 4.130. The Board has also considered additional, similar symptomatology not specifically addressed in the 70 percent criteria under the General Rating Formula but causing the appropriate level of occupational and social impairment for a 70 percent rating, under the General Rating Formula. See again Mauerhan, 16 Vet. App. at 442. In making this determination that a 70 percent rating is warranted, the Board has reviewed both the medical and lay evidence of record, including lay statements from the Veteran and his Agent; VA inpatient and outpatient mental health treatment records dated from 2008 to 2021; VA psychiatric examinations and opinions dated from 2009 to 2021; employment records pertaining to his TDIU claim; and Chapter 31 VA vocational rehabilitation records. Much of the above medical and lay evidence is indicative of the level of occupational and social impairment required for a 70 percent rating under 38 C.F.R. § 4.130. That is, an April 2010 VA neuropsychological evaluation observed suicide ideation and "severe" depression. An October 2010 VA inpatient record confirmed a suicide attempt. Also, July 2011 VA inpatient records documented suicide ideation and "high" anxiety and depression. Various VA treatment records dated from 2009 to 2020, after performing mental health testing (e.g., BDI testing), surmised the Veteran's depression and anxiety was "moderately severe" to "severe" in nature. Without psychiatric medications and cognitive behavioral therapy and monitoring, his depression / hopelessness and anxiety were constant and severe and "persistent." Moreover, VA treatment records dated from 2011 to 2016 specifically found that the Veteran's lack of insight and difficulty concentrating were "severe" in the level of psychiatric impairment they cause. A June 2020 VA care coordination home telehealth treatment plan found that his behaviors and symptoms that have been present or would likely manifest in the absence of care coordination services are "severe" PTSD and "severe" depression. With regard to the level of occupational impairment, a March 2011 Request for Information (VA Form 3288) from a VA vocational rehabilitation social worker asserted that she has treated the Veteran at the VA mental health clinic for several years. He exhibited little to no improvement and was unable to maintain employment due to anger and irritability with other people. She opined she could not see him being able to work full-time due to service-connected psychiatric problems. A February 2011 VA general medical examination and a January 2016 VA PTSD psychiatric examination advised that the Veteran had not worked since 2010 due to his service-connected psychiatric disorder. He previously had been irritable and aggressive with co-workers. His psychiatric symptomatology also resulted in impaired impulse control, such as "unprovoked irritability with periods of violence," which is supportive of a 70 percent rating. Moreover, a January 2016 VA PTSD psychiatric examination determined the Veteran exhibited "difficulty in adapting to stressful circumstances, including work or a worklike setting," which is supportive of a 70 percent rating. See 38 C.F.R. § 4.130. On a January 2011 Request for Employment Information (VA Form 21-4192), the Veteran's previous employer reflected that the Veteran last worked as an assistant manager at a hardware store from July 2008 to April 2010. The employer advised the Veteran resigned by choice due to "too much pressure." In a September 2019 rating decision, the AOJ awarded the Veteran a TDIU, effective from April 26, 2010. This was due in part to the severity of his service-connected PTSD, in addition to his service-connected physical impairments (knees, cervical spine, upper extremity radiculopathy). With regard to the level of social impairment, the above medical and lay evidence also reveals that the Veteran has no friends. He only associates with family. He is unable to cooperate with others except family members. He enjoys very few activities, with the exception of going to church. He clearly has an "inability to establish and maintain effective relationships." Much of this evidence supports a 70 percent rating under 38 C.F.R. § 4.130 due to the level of social impairment. At times in the record from 2010 to 2021, the Veteran has reported suicidal thoughts. He was hospitalized in October 2010 and July 2011 at the VAMC for a suicide attempt. Moreover, recent precedent has shed additional light on disability pictures that involve suicidal ideation. Specifically, the Court has held that suicidal ideation is listed among the criteria for a 70 percent rating and the mere presence of suicidal ideation alone may render that rating appropriate, regardless of whether a claimant had any intent or plan to act on it or was hospitalized. See Bankhead, 29 Vet. App. at 20 ("[T]he presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas.") Therefore, the Board finds that this particular symptomatology of suicide ideation also lends support to a 70 percent rating under 38 C.F.R. § 4.130. Another important factor in support of a higher 70 percent rating is that many, but not all of the GAF scores in these records are indicative of "serious" psychiatric impairment. See e.g., March 2010 VA mental health note (GAF score of 50); October 2010 VA inpatient treatment (GAF scores of 45, 50, and less than 30 at one point); November 2010 and December 2010 VA treatment records (GAF scores of 45); February 2011 VA treatment record (GAF score of 45); March 2011 VA treatment record (GAF score of 45); July 2011 VA inpatient treatment (GAF scores of 40 and 45); October 2011 VA treatment record (GAF score of 45); January 2013, February 2013, March 2013, and April 2013 VA treatment records (GAF scores of 50); separate January 2013 VA treatment record (GAF score of 48); separate April 2013 VA treatment record (GAF score of 48); and January 2015 VA treatment record (GAF score of 45). Although the GAF score is not dispositive of the rating that should be assigned, it is nonetheless probative evidence to assist in making this important determination. 38 C.F.R. §§ 4.2, 4.6. The above GAF scores are fully supportive of a higher 70 percent rating throughout the entire appeal period, when viewed in the context of the Veteran's level of occupational and social impairment documented above. In summary, much of the above evidence supports a 70 percent rating for the Veteran's PTSD under 38 C.F.R. § 4.130, throughout the entire appeal period, even though several of the requirements for a higher rating are not shown. See Mauerhan, 16 Vet. App. 436 (stating that the rating criteria provide guidance as to the severity of symptoms contemplated for each rating; they are not all-encompassing or an exhaustive list). His psychiatric symptomatology results in occupational and social impairment, with deficiencies in most areas, indicative of a 70 percent rating. See 38 C.F.R. § 4.130. However, upon review of the evidence, the Veteran does not meet the criteria for an increased 100 percent rating for his service-connected PTSD. 38 C.F.R. § 4.7. That is, the medical and lay evidence of record is not indicative of someone with psychiatric symptomatology causing total occupational and social impairment, which is required for the 100 percent rating. 38 C.F.R. § 4.130. In adjudicating this claim, the Board has also considered additional, similar symptomatology not specifically addressed in the 100 percent criteria under the General Rating Formula, but still causing the appropriate level of occupational and social impairment for a 100 percent rating. See again Mauerhan, 16 Vet. App. at 442. In making this determination that a 100 percent rating is not warranted, the Board has reviewed both the medical and lay evidence of record, including lay statements from the Veteran and his Agent. Initially, with regard to total occupational impairment, it is acknowledged that the Veteran has already been awarded a TDIU, effective from April 26, 2010. This is due in part to the severity of his service-connected PTSD. As such, the criterion of "total occupational impairment" under 38 C.F.R. § 4.130 is arguably present for the Veteran at this time for his PTSD disability. But most importantly, the Board finds that the Veteran does not exhibit "total" social impairment required for a 100 percent rating, in light of the evidence of record already discussed in detail above, as well as the evidence to follow below. See 38 C.F.R. § 4.130. A close review of VA treatment records and VA examinations dated from 2008 to 2021 reveal the following: The Veteran has been married three times. For the past 14 years, the Veteran is married to his now third wife. He has a distant relationship with a son from a previous marriage, with whom he talks "occasionally." He has also experienced difficulties with a stepson. His daughter by his third wife and his stepson live with him and his third wife in a "safe," "stable" home environment. Despite experiencing "low energy" due to his severe depression, he continues to interact "meaningfully" with his family and reports he has been home schooling his daughter. During the appeal, he and his wife underwent marriage counseling due to his irritability, disagreement about parenting duties, and financial issues. But more recently, they are no longer in counseling, and are spending more time together. He goes out to restaurants with his wife "daily." In 2021 they reported they were "looking forward" to moving into a new house together. His relationship with numerous family members (including his sisters) and his mother who live close by was described as "good." See January 2016 VA PTSD psychiatric examination. For leisure, the Veteran plays video games with his daughter. On a typical day he transports his family to appointments, cleans around the house, and cuts his grass, despite experiencing depression and panic attacks. He attends church several times a week. He has never been homeless. He was also able to interact with his VA therapy counselors from 2010 to 2021. With regard to total social impairment, therefore, he can still maintain some relationships, albeit with significant limitations and tension. He has no friends except his acquaintances at church. Regardless, the Board notes that the 70 percent evaluation he now has for his service-connected PTSD already encompasses an inability to establish and maintain effective relationships. In short, the most probative evidence of record fails to reveal "total social impairment" for the Veteran during the course of the appeal, which is required for a higher 100 percent rating. 38 C.F.R. § 4.130. With regard to total social impairment, while it is noted that at times the Veteran had some severe symptoms found only in the 100 percent rating criteria category, the Veteran still retains the ability to manage and maintain some social relationships with his family. The Board has relied on the Veteran's own statements concerning his continued relationship with his wife and relationship with his daughter and other family members. The Board recognizes that the Veteran's severe PTSD symptoms interfere with his life, but the 100 percent disability rating contemplates both total occupational and social impairment a very high standard. And although the Veteran has shown that his PTSD has exacted a toll on his social interactions, he has not shown total social impairment as evidenced by his continued relationship with his wife and daughter and son and stepson and other family members. "Total" is defined as "whole, not divided; full; complete," and "utter, absolute." Black's Law Dictionary, 1498 (7th ed. 1999). Although he has significant impairment in his social relations, he is not precluded from social relations. Once again, the Board emphasizes that the clinical and lay evidence of record supports significant social impairment for the Veteran, but not "total" social impairment. 38 C.F.R. § 4.130. Most importantly, no VA or private mental health professional of record assessed the Veteran's service-connected PTSD as causing "total occupational and social impairment," which is required for a higher 100 percent rating. That is, the most probative evidence of record did not demonstrate or assess total social impairment due to any of his documented symptoms discussed in great detail above. See again Vazquez-Claudio, 713 F.3d at 118 (the Veteran's psychiatric symptoms must cause the level of occupational and social impairment specified in the General Rating Formula). The Board finds the severity, frequency, and duration of any of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. In summary, the evidence of record weighs more heavily against an increased 100 percent rating for the Veteran. The Veteran is adequately compensated for his level of occupational and social impairment for his PTSD by way of a 70 percent rating. See 38 C.F.R. § 4.130. The Board acknowledges that on a few occasions the clinical evidence of record has noted some of the symptoms listed under the 100 percent rating criteria for psychiatric disorders. See 38 C.F.R. § 4.130. That is, there are occasions when the Veteran reported auditory or visual hallucinations, flashbacks, nightmares, and some other PTSD-related symptoms that are unlisted in the rating criteria. (However, the Board emphasizes that in VA treatment records and VA examinations dated from 2008 to 2021, there were dozens of other occasions in which the Veteran denied this symptomatology). Any auditory or visual hallucinations he experiences are not "persistent" in nature. Crucially, with the exception of several of his PTSD-related symptoms, given the limited severity and frequency and duration of the Veteran's symptoms described above in all other evidence of record (see 38 C.F.R. § 4.126(a)), psychiatric symptomatology causing "total occupational and social impairment" is not shown here. See again Vazquez-Claudio, 713 F.3d at 118 (the Veteran's psychiatric symptoms must cause the level of occupational and social impairment specified in the General Rating Formula). That is, in many instances in the record as alluded to above, the Veteran did not exhibit or even denied the existence of the above symptomatology and behavior, meaning that the favorable evidence, although probative, is outlier evidence that is outweighed by all other evidence not supportive of his psychiatric symptoms causing "total social impairment." See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (noting that the Board, as fact finder, is responsible for assessing the credibility, competence, and probative value of evidence). The Board has a duty, as finder of fact, to analyze the probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Simply stated, the evidence of record weighs more heavily against a maximum 100 percent rating for PTSD. The Veteran's level of social impairment, although significant, is not total or complete in nature. With regard to the ameliorative effects of the Veteran's various psychiatric medications (Prazosin, Bupropion, Trazodone, Duloxetine, and others), the Board notes that the plain language of the criteria for a 10 percent rating under the General Rating Formula for Mental Disorders specifically contemplates the effects of psychiatric medication. Consequently, Jones v. Shinseki, 26 Vet. App. 56 (2012) does not apply here. It follows that the Board's evaluation of the Veteran's service-connected psychiatric problems may include the ameliorative effects of his various psychiatric medications documented in the record. See McCarroll v. McDonald, 28 Vet. App. 267, 271-73 (2016) (where the plain language of the diagnostic code contemplates the effects of medication, Jones is not applicable). Moreover, the Veteran's GAF scores listed above are indicative of moderate to serious / severe impairment, but not full and complete impairment. Thus, his GAF scores in the 30s, 40s and 50s from 2008 to 2015 provide evidence against a total 100 percent rating for PTSD. Although the VA examiner's use of this descriptive term is not altogether dispositive of the rating that should be assigned, it is nonetheless probative evidence to assist in making this important determination. 38 C.F.R. §§ 4.2, 4.6. Accordingly, the Board finds that the evidence supports a higher 70 percent rating, but no greater, for the Veteran's service-connected PTSD, throughout the entire appeal period. 38 C.F.R. § 4.3. In fact, neither the Veteran nor his Agent has alleged that his service-connected PTSD warrants the maximum 100 percent rating. Finally, for the Veteran's service-connected PTSD, neither the Veteran nor his Agent has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record)." See also Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P.S. Rubin, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.