Citation Nr: 0007351 Decision Date: 03/20/00 Archive Date: 03/23/00 DOCKET NO. 94-29 607 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to a date earlier than April 28, 1998 for the assignment of a 100 percent disability rating for an anxiety disorder with post-traumatic stress disorder (PTSD) symptoms. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Vito A. Clementi, Counsel INTRODUCTION The appellant had active duty from October 1967 to January 1970. Service in Vietnam is indicated by the evidence of record. The appellant testified at a personal hearing conducted by the undersigned in April 1999. This matter was last before the Board of Veterans' Appeals (Board) in August 1999, on appeal from rating decisions of the Houston, Texas, Department of Veterans Affairs (VA) Regional Office (RO). Upon its last review, the Board denied entitlement to service connection for the loss of two toes of the left foot, secondary to service-connected tinea pedis; and also denied the appellant entitlement to compensation benefits for the loss of two toes of the left foot claimed as resulting from VA medical treatment under the provisions of 38 U.S.C.A § 1151. In August 1999, the Board noted that the appellant had not presented testimony at the April 1999 travel board hearing relative to this earlier effective date claim, which had been certified for the Board's review with the claims relative to the loss of the appellant's toes. The Board therefore remanded the case for clarification regarding whether he desired to pursue the earlier effective date claim, and if so to determine whether he desired to present testimony at another personal hearing. The record reflects that by letter dated in September 1999, the RO requested that the appellant advise it if he desired to continue his appeal with regard to the issue in question, and if so, whether he desired a hearing. The Board notes that the letter advising the appellant was forwarded to the same address that he had previously designated, and the letter was not returned as undeliverable. In the letter, the RO also suggested that the appellant consult his representative. A copy of the letter was also forwarded to the representative. By correspondence received in October 1999, the appellant advised the RO that he desired to continue his appeal with regard to the effective date issue. He did not refer to a continued desire to appear before a hearing. A December 1999 statement was thereafter received from the appellant's representative, in which the representative requests that the Board carefully consider all evidence. The representative's letter is silent with regard to the appellant's desire to present testimony before a hearing. Applicable regulation provides in part that a hearing on appeal will be granted if an appellant, or an appellant's representative acting on his behalf, expresses a desire to appear in person. 38 C.F.R. § 20.700(a) (1999). In this matter, both the appellant and his representative have been afforded an opportunity to clarify whether the appellant desires a hearing specifically with regard to the issue now before the Board. The responses from both the appellant and his representative are silent as to any continuing request for a hearing. The Board therefore concludes that the appellant does not wish to present testimony relative to the claim at issue, and the Board will therefore proceed to review the claim at issue. See e.g., Stuckey v. West, 13 Vet. App. 163, 175 (1999), (Observing that in a case where the veteran was "quite actively" represented by qualified veterans' representative, that Congress and VA have provided for accredited representatives to assist claimants to "navigate the claims process," and that these representatives "may be far more attuned to the procedural esoterica than most lawyers." ). FINDING OF FACT Since January 22, 1992, the appellant's service-connected psychiatric disorder has resulted in severe impairment in the ability to establish and maintain effective or favorable relationships with people, and has prevented the appellant from securing or following a substantially gainful occupation. CONCLUSION OF LAW The assignment of an effective date of January 22, 1992 for the award of a 100 percent schedular rating for the appellant's service-connected psychiatric disorder is warranted. 38 U.S.C.A. § 5110 (West 1991); 38 C.F.R. §§ 3.400, 4.16, 4.132 (Diagnostic Code 9400) (1996). REASONS AND BASES FOR FINDING AND CONCLUSION Introduction Service connection has been granted for anxiety disorder with symptoms of PTSD, effective from January 22, 1992. A 30 percent disability rating was assigned by the RO from January 22, 1992 and a 100 percent disability rating has been assigned from April 28, 1998. The appellant in essence contends that the effective date for the award of a 100 percent disability evaluation for PTSD should be earlier than April 1998. By law, the Board's statement of reasons and bases for its findings and conclusions as ton all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990); 38 U.S.C.A. § 7104(d)(1) (West 1991). With this requirement of law in mind, and in light of the appellant's contentions, a factual review of evidence of record as found in the appellant's claims folder would be helpful to an understanding of the Board's decision. The Board will then review the relevant law and regulations, and then proceed to its discussion of the disposition of the claim. Factual Background The appellant was discharged from military service in January 1970. In a July 1970 rating decision, the RO denied the appellant's claim of entitlement to service connection for a psychiatric disorder. In April 1973 and March 1974 decisions, the Board denied the appellant's claim. On January 22, 1992, the RO received a statement in support of claim (VA Form 21-4138) signed by the appellant. The appellant requested an increased rating for what he characterized as a service-connected neurosis. The RO, noting that service connection was not in effect for a psychiatric disability, treated this as a request to reopen the appellant's claim of entitlement to service connection for a psychiatric disability. The RO contacted the appellant and requested additional evidence. On April 22, 1992, the appellant submitted another VA Form 21-4138 in which he indicated that he was receiving psychiatric treatment at a VA facility. The RO subsequently obtained VA outpatient treatment records. On January 16, 1992, the appellant was noted in a VA medical record progress note to have a diagnostic impression of "severe" PTSD. It was noted that the appellant was then reporting that he had been unemployed for the previous 5 years due to conflict and irritability. He stated that he had nightmares every night; that he slept with 3 firearms, and that he was then experiencing daily flashbacks. The examiner stated that the appellant had "violent thoughts" but that he appeared to be in good control. Another examiner observed that the appellant had been unable to work except for his brother who was recently deceased, and that the appellant then had no suicidal ideation, but that he was somewhat paranoid. The appellant underwent a VA PTSD examination in August 1992. He complained of military-service related nightmares, and related that he had been fired from good jobs because of his "attitude." He described this attitude as involving a quick temper, and reported that he tried to isolate himself from others. He reported that he had been married three times, and was then separated from his third wife. He stated that when he could not sleep at night, it was easier for him to sleep in the daytime. He added that he did not like to be touched unexpectedly, and that he had sometimes struck people when they touched him in this manner. He reported difficulty concentrating. Upon mental status examination, he was noted to be tense, anxious, and irritable and his affect was constricted. His speech was normal in rate and amount and its content was relevant and goal-directed. There was adduced no evidence of hallucinations or of delusions, and the appellant was oriented as to time, place and person. The examiner specifically noted that a prior diagnosis of a paranoid personality disorder, as had been rendered during the course of the appellant's military service, was erroneous. He observed that the appellant was then under treatment for psychiatric symptoms consisting of sleep disturbances, nightmares, irritability and anxiety, and that "documentation indicate[d] that these symptoms had originated during [the appellant's] military service. The record reflects that by rating decision dated in September 1992, service connection was granted for a generalized anxiety disorder with features of PTSD. A 30 percent disability evaluation was assigned, effective April 22, 1992. On October 27, 1992, the effective date of the grant of service connection was amended to January 22, 1992 on the basis of a finding of clear and unmistakable error, as it was noted that it was in January 1992 that the appellant's reopened claim of entitlement to service connection for a psychiatric disorder had been received. The RO received a communication from the appellant on October 7, 1992 in which he stated that his "neurosis [was] much worse than you have stated." In a letter received by the RO in December 1992, the appellant reiterated that he had previously applied for a disability rating greater than had been assigned, and that his psychiatric "problem [was] getting worse." The record does not reflect that a Statement of the Case as to the matter of the level of the disability was issued by the RO following receipt of the appellant's October 1992 submission. By rating decisions dated in February and June 1993, the assigned 30 percent disability rating was confirmed. In July 1993, the appellant submitted a VA form 9, Appeal to Board of Veterans' Appeals, in which he stated his contentions relative to the severity of his psychiatric disorder. In particular, the appellant challenged the findings of the RO as to how it concluded he did not have considerable social and industrial impairment. In a March 1993 VA medical record, it was noted that the appellant had chronic and severe PTSD. It was noted that the appellant had been in a PTSD treatment program since January 1992, and that he had not been detected to be using illegal drug or alcohol. The author of the note observed that it was "evident" that the appellant had "severe limitations vocationally and interpersonally." It was observed that it was "unlikely that the [appellant] will ever be able to hold a job." In an October 1993 VA medical record progress note, M.A.A., Ph.D. reported that the appellant had chronic and severe PTSD, and worsening health problems with increasing symptoms of his psychiatric disorder. She observed that the appellant's nightmares had increased, as had his hostility, "creating family stress." In a November 1993 interim report summary, Dr. M.A.A. stated that although the appellant continued to regularly attend a PTSD support group, his social functioning was severely impaired and that his vocational prospects were poor due to the psychiatric disorder. She observed that the appellant was unable to "get along" with others, and that he was having "flashbacks" and nightmares at least three times per week with insomnia. She stated that the appellant was "totally disabled due to extreme symptoms of PTSD. In February 1994, the RO issued a rating decision which denied the appellant a disability rating in excess of 30 percent for his service-connected psychiatric disability. In March 1994, the appellant filed a VA Form 21-4138 in which he stated that he disagreed with "your decision to deny me . . . an increase on" the service-connected anxiety disorder with features of PTSD. In a July 1994 VA interim report summary, Dr. M.A.A. noted that while the appellant continued to readily participate in a PTSD support group, he was often deterred by the numbers of other participants. She noted that he displayed "extreme mistrust of others bordering on paranoid ideation," and that this diminished his ability to interact with others and rendered him socially isolated. She added that the appellant's current mental condition, in conjunction with his physical limitations, had rendered him unemployable. She assessed the appellant's PTSD to be chronic and severe with paranoia. In an August 1994 VA medical treatment note, the appellant reported that he was having "flashbacks" as saw scenes of Vietnam as he walked down the street. He reported that he was not aware that these scenes were unreal until after the experiences were over. At a November 1994 personal hearing before a hearing officer at the RO, the appellant testified in substance that other people, particularly his nephews, did not want to be around him. He stated that he was focused on Vietnam, and that when this bored others he would become angry about it. He stated that he did not like to take orders from supervisors, and that he would quit jobs because of it. He stated that the last time this occurred was about six years previously, when he quit his job. He stated that he felt like he never truly slept, but that he felt he only rested. He stated that he had a lot of "continuously bad dreams." In a December 1994 VA medical treatment note, the appellant reported that he was having increasingly worse nightmares due to PTSD, and that he was experiencing enuresis due to fear. The appellant underwent a VA psychiatric examination in January 1995. He related that he felt "angry and anxious," and that he did not sleep well because of nightmares about Vietnam. He stated that these nightmares involved seeing dead friends from Vietnam, and that when these images occurred he was uncertain if he was sleeping or awake. He stated that he heard explosions like mortars and rockets in his dreams, and sometimes heard these when he was awake. He reported that he was separated from his third wife, and that he occasionally visited his children. The appellant reported that he was not employed. He added that although he had several jobs in the past, he was unable to keep them because he could not get along with others. He stated that he did not watch television because it "shows a lot of war." He stated that he could not tolerate anyone walking up behind him or touching him unexpectedly. He was diagnosed to have an anxiety disorder with features of PTSD. The appellant was hospitalized from May 18 to June 2, 1995. Upon admission, he reported a one-month history of depression characterized by sleeplessness, decreased energy, loss of appetite, suicidal ideation and psychomotor retardation. he denied manic symptoms. He related a history of PTSD symptoms of frequent nightmares about Vietnam, "flashbacks," auditory and visual hallucinations, increased started responses to loud noises and smells, difficulty concentrating, outbursts of anger and occasional suicidal ideation. He reported that he and his family had maintained minimal contact by mutual consent, and that they avoided each other. Upon mental status examination, he was noted to appear "quite nervous," and he could not remain still. The examiner noted that the appellant was constantly getting out of bed and looking out of the window. He was noted to have poor eye contact, and he was cooperative except that he had to be pressed to provide more informative answers. His affect was noted to be depressed and anxious, and his mood was nervous and depressed. There were no homicidal ideations noted, and although the appellant reported auditory hallucinations, these appeared to be more intrusive thoughts. He was diagnosed to have unspecified depression and PTSD. His global assessment of functioning (GAF) score was 55 for the present year, and 65 for the previous year. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). At an October 1995 personal hearing before a hearing officer at the RO, the appellant testified in substance that participation in the PTSD self-help group and his prescribed medication did not assist him. He stated that he spent his days in his room; that he would not watch television, and that he had no car. He added that although he had neighbors, they had "nothing to do" with him, because his neighbors said that the appellant was "off into a different world." The appellant underwent a VA psychiatric examination in July 1997. He reported that he had been arrested for assault and damage to private property shortly after his discharge from military service, and that he had continued to have fights until he was prescribed medication for PTSD. He stated that he had self-medicated his PTSD symptoms by the abuse of alcohol. He reported that he had been married four times since being discharged, and that he had three children. He reported that he did not have any close relationships with the children, and that he had been divorced because of his irritability. The appellant reported that he experienced flashbacks, intrusive recollections several times per week, distressing dreams every night, and that he avoided watching war movies, television, and being in crowds, stores, or any place that was "noisy and busy." He stated that he did nothing for enjoyment, and that he stayed at his nephew's house. He added that he was close to no one, and that he did not care about anything. He stated that he had difficulty concentrating, and that he did not like it when someone would walk up behind him. The examiner diagnosed the appellant to have PTSD. He observed that the results of clinical testing were of questionable validity, because it appeared that the appellant responded in such a way as to create an unfavorable impression by exaggerating certain pathological or undesirable personal characteristics. His GAF score was 55. The examiner commented that the appellant had both PTSD and a borderline personality disorder. This condition was chronic and was expected to remain permanent. The appellant underwent a VA psychiatric examination in April 1998. He again reported enuresis, nightmares, recurrent intrusive recollections of Vietnam, irritability, and stated that he "hardly sleeps." He was noted to be unshaven and dressed in dirty clothes. The appellant stated that he was constantly nervous, anxious, angry and that he had difficulty in relating to others. He stated that he did not go around his family. The examiner reported that the appellant lived with different persons, and that he then staying with a fellow veteran. The appellant related that he did not attend church, and that he had no friends, no interests, and that he was depressed. The examiner opined that the appellant had a GAF score of 40. By rating decision dated in October 1998, the RO increased the appellant's assigned disability rating relative to the psychiatric disorder to 100 percent, effective April 28, 1998. The effective date was established as it was the date of the last VA medical examination, reflecting increased symptoms of the disorder. Relevant Law and Regulation Disability Ratings; In General Disability determinations are determined through the application of a schedule of ratings (Schedule), which is predicated upon the average impairment of earning capacity. Separate diagnostic codes identify various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321(a) and Part 4. Rating criteria for mental disorders During the pendency of this appeal, the regulations pertaining to mental disorders were revised. Psychiatric disabilities are rated under the portion of the Schedule for Rating Disabilities that pertain to mental disorders. Prior to November 7, 1996, a generalized anxiety disorder was rated under 38 C.F.R. § 4.132 (1996). Effective November 7, 1996, the rating schedule for mental disorders was amended and redesignated as 38 C.F.R. § 4.130. Therefore, the appellant's claim will be evaluated under both the new and old law. See Karnas v. Derwinski, 1 Vet. App. 308 (1991) [where the law or regulation governing the case changes after a claim has been filed or reopened, but before the administrative or judicial appeal has been concluded, the version most favorable to the veteran will apply]. Before November 7, 1996, the Schedule read as follows: 100% The attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. Totally incapacitating psychoneurotic, symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. Demonstrably unable to obtain or retain employment. 70% Ability to establish and maintain effective or favorable relationships with people is severely impaired. The psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. 50% Ability to establish or maintain effective or favorable relationships with people is considerably impaired. By reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. 30% Definite impairment in the ability to establish or maintain effective and wholesome relationships with people. The psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9400 (1996). Under the previously applicable regulation, the finding of only one of the criteria listed for a particular psychiatric rating may be sufficient to support the assignment of that rating. Johnson v. Brown, 7 Vet. App. 95, 97 (1994). Words such as "mild," "considerable" and "severe" were not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (1998). The use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C.A. § 7104 (West 1991); 38 C.F.R. §§ 4.2, 4.6 (1998). Formerly under 38 C.F.R. § 4.16(c) (1996), where the only compensable service-connected disability is a mental disorder assigned a 70 percent evaluation, and such mental disorder precluded a veteran from securing or following a substantially gainful occupation, the mental disorder was to be assigned a 100 percent schedular evaluation under the appropriate diagnostic code. Although this subsection of the regulation has been repealed, it was in effect at the time that the appellant brought his claim, and it is therefore applicable here, pursuant to Karnas. On and after November 7, 1996, the VA Schedule for Rating Disabilities was amended. The pertinent provision now reads as follows: 100% Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of 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. 70% 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 worklike setting); inability to establish and maintain effective relationships. 50% 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 effective work and social relationships. 30% 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, Diagnostic Code 9400 (1998). Effective Dates The method for determining the effective date of a grant of service connection is set forth in 38 U.S.C.A. § 5110(a), as well as 38 C.F.R. § 3.400. With respect to the assignment of an effective date, the applicable law indicates that, except as otherwise provided, the effective date of an award based on an original claim shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C.A. § 5110(a) (West 1991). The date of entitlement to an award of service connection is the day following separation from active service or date entitlement arose if the claim is received within one year after separation from service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(b)(2)(i) (1998). A rating action becomes final unless it is appealed within one year. After a claim has been denied by a rating decision that was unappealed or from which an appeal was not perfected, it may be challenged on the basis that it contained clear and unmistakable error. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104(a), 3.105, 20.200, 20.302, 20.1103 (1998). In pertinent part, the effective date of an award based on a claim reopened after final disallowance shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(q)(1)(ii) and § 3.400(r). The general rule with respect to the effective date of an award of increased compensation is that the effective date of such award "shall not be earlier than the date of receipt of application therefor." 38 U.S.C.A. § 5110(a) (West 1991). See 38 C.F.R. § 3.400(o)(1) (1998). An exception to that rule applies, however, under circumstances where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. In that regard, the law provides that the effective date of the award "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C.A. § 5110(b)(2) (West 1991). See 38 C.F.R. § 3.400(o)(2) (1998); Harper v. Brown, 10 Vet. App. 125 (1997). The term "increase" as used in 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400 means an increase to the next disability level. Hazan v. Gober, 10 Vet. App. 511 (1997). In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. Cf. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Fenderson, the Court also discussed the concept of the "staging" of ratings, and noted that where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Analysis The issue on appeal As an initial matter, the Board notes that the RO has treated this claim as one for entitlement to an earlier effective date for an increased disability rating, applying the provisions of 38 C.F.R. § 3.400(o). The RO, in the February 1999 Statement of the Case, in essence indicated that the appellant did not appeal the initial assignment of a 30 percent disability rating and that he filed a claim for an increased rating in February 1994. According to the RO, during the pendency of the appellant's 1994 claim of entitlement to an increased disability rating, it became factually ascertainable that the service-connected psychiatric disability was 100 percent disabling. See 38 C.F.R. § 3.400(o). For the reasons expressed below, the Board believes that the appeal in reality revolves around the initial assignment of the disability rating for the appellant's service-connected disability, see Fenderson, rather than the date of assignment of an increased rating. Appellate review is initiated by the filing of a notice of disagreement, ("NOD"), with a rating decision, which, if not filed within one year from the date of mailing of notice of the rating decision, the underlying decision "shall become final and the claim will not thereafter be reopened or allowed," except as otherwise provided in applicable statutes and regulations. 38 U.S.C. §§ 7105(a),(b)(1),(c). An NOD is "[a] written communication from a claimant . . . expressing dissatisfaction or disagreement with an adjudicative determination by the agency of original jurisdiction and a desire to contest the result." While there is no special wording required in a NOD, it "must be in terms which can be reasonably construed as disagreement with that determination and a desire for appellate review." 38 C.F.R. § 20.201; Stokes v. Derwinski, 1 Vet. App. 201, 203 (1991); See Prenzler v. Derwinski, 928 F.2d 392, 394 (Fed.Cir. 1991); Hauck v. Brown, 6 Vet. App. 518, 519 (1994). The appellant's October 1992 correspondence is clearly an NOD within the meaning of applicable law, as it indicated that he desired appellate review of the September 1992 rating decision to the extent that it assigned his psychiatric disorder a 30 percent disability rating. The RO should have then issued a Statement of the Case as to the matter of the assigned disability rating. The RO's failure to do so in essence constituted a denial of his claim. See Jones v. West, 12 Vet.App. 98 (1998); see also In re Fee Agreement of Smith, 10 Vet.App. 311, 314 (1997), (Observing that "[w]here the Board fails to adjudicate a claim that was reasonably raised before it, the net outcome for the veteran amounts to a denial of the benefit sought."). Further, the appellant's July 1993 VA Form 9 constituted a substantive appeal as to the matter of the assigned disability rating. See 38 U.S.C.A § 7105(d)(3); 38 C.F.R. § 20.202. Although not recognized as such by the RO, this matter has been in appellate status ever since the filing of his NOD in October 1992. Thus, although the issue on appeal has been characterized as involving the establishment of an earlier effective date for an increased disability rating, the issue is more accurately characterized as involving the level of initial disability rating assigned for the service-connected psychiatric disorder, as well as rating levels thereafter. See Fenderson, supra. Discussion As a predicate matter to be resolved, the Board has scrutinized the record in this case and has identified no communication, hospital report or other document received prior to the appellant's statement, received on January 22, 1992 that may be construed as an informal claim for benefits. See Servello v. Derwinski, 3 Vet. App. 196 (1992). The Board has been unable to identify any informal application filed prior to January 22, 1992 that meets the requirements of either 38 C.F.R. §§ 3.155 or 3.157. The appellant and his representative have also not identified any such application. See Stuckey, supra. Accordingly, the date of the appellant's claim is January 22, 1992. As is noted above, the appellant's mental disorder had, several days before January 22, 1992, been evaluated as "severe" by a VA medical examiner. Scrutiny of the disability picture resulting from his mental disorder at that time reveals that the examiner's observation is supportable. He was noted to then be unemployed "due to conflict and irritability" and was "somewhat paranoid." The medical evidence of record generated at that time indicates that the appellant complained of nightmares "every night," "flashbacks," and violent thoughts. Although the examiner observed that the appellant appeared to be in "good control," he had violent thoughts and he was sleeping with three guns. As is noted above, in September 1992, the RO granted service connection for a generalized anxiety disorder with features of PTSD and assigned a 30 percent disability rating which, under the previously applicable schedular criteria, was indicative of "definite impairment." 38 C.F.R. § 4.132 (Diagnostic Code 9400) (1996). Upon review of the RO's findings in this regard, the Board is of then opinion that the appellant symptoms then constituted a disability picture more approximating those appropriately evaluated as 70 percent disabling under the then applicable Schedule. It cannot be doubted that the results of the August 1992 VA examination clearly reflect that the appellant had significant social impairment. This is evidenced by his own report of his "attitude," as well as his quick temper, attempts at isolation, and three marriages. The Board is cognizant in this regard that at the time of the September 1992 rating decision, social impairment per se was not to be used as the sole basis for any specific percentage evaluation, but was of value only in substantiating the degree of disability based on all of the findings. See 38 C.F.R. § 4.132, note 1 (1996); compare 38 C.F.R. § 4.126(b) (1999) (In evaluation of the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment.). It also cannot be doubted that all of the symptoms the appellant then reported had a substantial impact upon his capacity for employment. In their whole, the symptoms indicated that the appellant was then in substantial isolation from psychoneurotic symptoms (e.g., a quick temper, an inability to be approached from behind, an inability to be touched, "violent thoughts" and periodic violent outbursts). Moreover, these symptoms were of such severity and persistence (e.g., nightmares every night and daily "flashbacks") that the appellant's capacity to secure and retain employment was severely impaired, thus warranting a 70 percent disability rating under the then applicable Schedule. As is noted above, under the formerly applicable 38 C.F.R. § 4.16(c), a veteran having a single compensable service- connected mental disorder assigned a 70 percent evaluation was eligible for consideration of a 100 percent schedular evaluation if the evidence showed that the mental disorder precluded him from securing or following a substantially gainful occupation. 38 C.F.R. § 4.16(c) (1996). The initial opinion as to the effect of the appellant's psychiatric disorder on his employability is dated in March 1993, approximately seven months after the August 1992 VA mental disorders examination. At that time, the appellant's treating VA physician observed that the appellant had "severe" vocational and interpersonal psychiatric impairment, and that it was "unlikely that the [appellant] will ever be able to hold a job." Of particular significance with regard to 38 C.F.R. § 4.16(c)(1996), the Board notes that the appellant's treating physician had based her opinion upon observations made since January 1992 - the onset of the appellant's VA psychiatric treatment and the date he successfully reopened his claim of service connection for a mental disorder. The Board finds the physician's observation to be of particular probative value as to the effect of the appellant's psychiatric disorder upon his employability at the time approximately contemporaneous with the reopening of his claim. The physician's opinion of the appellant's apparent unemployability was then clearly based upon her observation of the appellant's symptoms and their effect since January 1992. Review of the record in its whole subsequent to March 1993 reveals that the appellant's symptoms and their severity have remained relatively constant since January 1992. In October 1993, the appellant's symptoms were again noted to be severe in nature. As was noted in August 1992, the appellant was described as unable to function with others; he had frequent nightmares, "flashbacks," and insomnia. Most critically, the appellant was then described as "totally disabled" due to "extreme" symptoms of his psychiatric disorder. With required application of the formerly applicable 38 C.F.R. § 4.16(c) under Karnas, supra, the Board is of the opinion that the appellant's psychiatric disorder precluded him from securing or following a substantially gainful occupation, and the assignment of a 100 percent disability for a mental disorder was then appropriate. 38 C.F.R. § 4.16(c) (1996). The level of severity of the appellant's psychiatric disorder is thereafter consistently demonstrated. In particular, it is evident that the appellant has been, since at least January 1992, isolated from his family and incapable of employment. There is no medical or evidence which stands for the proposition that the psychiatric disability has improved over the period of time in question. In its October 1998 rating decision granting the appellant a 100 percent disability rating, the RO found that the April 1998 VA psychiatric examination detected increased sleep disturbances, and feelings of paranoia, depression and worthlessness. The RO also noted that the appellant had then been assigned a GAF score of 40. It was upon these primary bases that the RO found the assignment of a 100 percent disability rating to be appropriate. The only significantly different evidentiary item generated during the course of the April 1998 VA medical examination, as opposed to the other evidence of record, was that the appellant was assigned a GAF score of 40. This is indicative of "some impairment in reality testing or communication" or "major impairment in several areas." See DSM-IV, and Carpenter, supra. However, as is noted above, the underlying symptomatology and its severity, and its effect upon the appellant's social and industrial capacity appears to have been relatively consistent since January 1992. In any event, the GAF score is not necessarily dispositive of the critical issue in this case: the determination of the appellant's level of disability arising from his psychiatric disorder. As is noted above, the Board's scrutiny must be upon all evidence of record, both "positive" and "negative" as to the merits of a claim. Gilbert, supra. Because by this decision the appellant is receiving a 100 percent disability evaluation effective January 1992 under the previously applicable schedule, the Board has not considered the currently applicable rating criteria. See Karnas, supra. CONTINUED ON NEXT PAGE ORDER An effective date of January 22, 1992 is granted for the assignment of a 100 percent disability rating for PTSD. Barry F. Bohan Member, Board of Veterans' Appeals In a July 1997 VA psychological evaluation, the appellant reported that enuresis had been troublesome during the course of his marriages, because this symptoms would eventually result in his wives refusing to sleep with him. GAF is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p.32.] GAF scores ranging between 61 to 70 reflect 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, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect 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). The RO construed the appellant's June 1995 NOD to an April 1995 rating decision as to the severity of the psychiatric disorder as a new claim, because he did not earlier file an NOD relative to a February 1994 rating decision. In due course, the RO denied the appellant an increased rating in July 1995, to which the appellant filed a timely NOD in August 1995. The Board's findings as to the procedural record of this case are therefore different than those of the RO. Because this decision clearly inures to the benefit of the appellant, no prejudice results from the Board's decision relative to the efficacy of his October 1992 correspondence. See Bernard v. Brown, 4 Vet. App. 384 (1993) (Holding in part that when the Board addresses in its decision a question that has not been addressed by the RO, it must consider whether the appellant has been given adequate notice to respond and, if not, whether he has been prejudiced thereby. ). Under the former, an informal claim consists of any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of the claimant who is not sui juris. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a). Under 38 C.F.R. § 3.157, an informal claim may consist of a report of examination or hospitalization. The provisions of this paragraph apply only when such reports relate to examination or treatment of a disability for which service- connection has previously been established or when a claim specifying the benefit sought is received within one year from the date of such examination, treatment or hospital admission. Moreover, 38 C.F.R. § 3.157(b) provides that the date of an outpatient or hospital examination or admission to a VA or uniformed service hospital will be accepted as the date of receipt of an informal claim for increased benefits, or an informal claim to reopen, with respect to disabilities for which service connection has been granted. It has been held that a report of examination or hospitalization may be accepted as an informal claim for benefits, but only after there has been a prior allowance or disallowance of a formal claim for compensation. Crawford v. Brown, 5 Vet. App. 33, 35-6 (1993). The Board observes that as of the time of the September 1992 rating decision, service connection was also in effect for a scar of the left groin and tinea pedis. These disabilities were both assigned zero percent ratings.