Citation Nr: 0000113 Decision Date: 01/04/00 Archive Date: 12/28/01 DOCKET NO. 97 - 16 994 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES Entitlement to a rating in excess of 50 percent for post- traumatic stress disorder. Entitlement to a total disability rating based on unemployability due to service-connected disability under the provisions of 38 C.F.R. § 4.16. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Frank L. Christian, Counsel INTRODUCTION The veteran served on active duty from July 1970 to July 1973, including service in the Republic of Vietnam from September 1970 to July 1971. On August 26, 1998, the Board of Veterans' Appeals (Board) issued a decision which the veteran appealed to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a Joint Motion to Remand, the Court issued its Order, dated February 18, 1999, vacating that decision and remanding the case to the Board for another decision, taking into consideration the matters raised in its order. In that Order, the Court indicated that the Board had impermissibly substituted its judgment for that contained in the record, a violation of the Court's holding in Colvin v. Derwinski, 1 Vet. App.171, 175 (1991); that the Board had failed to apply the provisions of 38 C.F.R. § 3.102 requiring application of the benefit of the doubt; that the Board's decision did not comport with the Court's holding in Mittleider v. West, 11 Vet. App. 181 (1998), which precludes the Board from differentiating between the symptomatology attributable to a nonservice-connected disability and that attributable to a service-connected disability in the absence of medical evidence making such distinction; and that the Board has failed to provide an adequate statement of reasons or bases for its decision that the appellant was not entitled to a rating in excess of 50 percent for PTSD, or to a total disability rating based on individual unemployability due to service-connected disability. Pursuant to the Court's Order, the Board notified the veteran and his representative by letter of June 11, 1999, of their right to submit additional argument and evidence in support of his claims within 90 days of the date of that notification letter. In September 1999, the veteran's representative submitted an informal hearing presentation reiterating the assertions that the veteran was entitled to a rating in excess of 50 percent for PTSD, and to a total disability rating based on individual unemployability due to service- connected disability. An opinion by the General Counsel of the Department of Veterans Affairs, dated June 7, 1999 (VAOPGCPREC 6-99), held that a claim for a total disability rating based on individual unemployability for a particular service-connected disability may not be considered when a schedular 100 percent rating is already in effect for another disability. That opinion further held that no additional monetary benefit would be available in the hypothetical case of a veteran having one service-connected disability under the rating schedule and another, separate disability rated totally disabling due to individual unemployability under 38 C.F.R. Part 4, § 4.16(a). Further, that holding stated that the availability of additional procedural protections applicable under 38 C.F.R. § 3.343(c) in case of a total disability rating based on individual unemployability would not provide a basis for consideration of a rating under 38 C.F.R. Part 4, § 4.16(a) where the veteran already has a service-connected disability rated 100 percent under the rating schedule. In view of the Board's determination that the veteran is entitled to a schedular 100 percent disability rating for his service-connected PTSD, effective March 25, 1996, the Board does not reach the issue of entitlement to a total disability rating based on individual unemployability due to service- connected disability. Vettese v. Brown, 7 Vet. App. 31, 34- 35 (1994); VAOPGCPREC 6-99. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the instant appeal has been obtained by the RO. 2. The veteran's sole service-connected disability is a mental disability, diagnosed as PTSD, currently evaluated as 50 percent disabling. 3. The clinical and other data establish that the veteran's service-connected PTSD is currently productive of virtual isolation in the community; that his PTSD symptomatology results in such symptoms as gross impairment in communication with members of his own family as well as prospective employers; and that the severity of his PTSD symptomatology is such as to render him effectively incapable of securing and retaining substantially gainful employment, effective March 25, 1996, based upon the criteria in effect prior to and on and after November 7, 1996. CONCLUSION OF LAW The criteria for an increased schedular rating of 100 percent for PTSD is warranted under the criteria in effect prior to and on and after November 7, 1996. 38 U.S.C.A. § 1155, 5107(a) (West 1991); 38 C.F.R. Part 4, §§ 4.16(c), 4.132, Diagnostic Code 9411(prior to November 7, 1996); 38 C.F.R. Part 4, §§ 4.16(a), 4.126, Diagnostic Code 9411(on and after November 7, 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board finds that the appellant's claim is plausible and is thus "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). A claim for an increased rating is generally well grounded when the appellant indicates that he has suffered an increase in disability. Proscelle v. Derwinski, 2 Vet. App. 629 (1992); Drosky v. Brown, 10 Vet. App. 251 (1997). We further find that the appellant has submitted evidence in support of his claims, that the facts relevant to the issues on appeal have been properly developed, and that the statutory obligation of VA to assist the veteran in the development of his claims has been satisfied. 38 U.S.C.A. § 5107(a)(West 1991). In that connection, we note that the RO has obtained available evidence from all sources identified by the veteran, that he has been afforded a personal hearing, and that he underwent comprehensive VA psychiatric examinations in connection with his claims in December 1995 and in November 1997. On appellate review, the Board sees no areas in which further development might be productive. The appellant contends that the RO erred in failing to grant entitlement to a rating in excess of 50 percent for PTSD and in failing to grant a total disability rating based on unemployability due to service-connected disability under the provisions of 38 C.F.R. § 4.16 because it did not take into account or properly weigh the medical and other evidence of record. It is contended that the veteran is depressed all the time and avoids crowds; that he stays at home, dozes, and watches television; that he is unable to take his psychotropic medications because of his blood pressure problems; that he has dreams two or three times a week, brief flashbacks, and daily intrusive memories of Vietnam experiences; that he gets only two or three hours sleep per night; that he does not attend church or get involved with his family, his neighbors, or the PTA; that he experiences anhedonia, social isolation, significant social impairment, inability to get along with his spouse, grandchildren and others; and that he has suicidal ideation and memory loss. It is specifically contended that the veteran is entitled to an increased disability rating based upon his reported symptomatology, as well as a total disability rating based on service-connected disability under the provisions of 38 C.F.R. § 4.16(c) (1999). In accordance with 38 C.F.R. §§ 4.1 and 4.2 (1999) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the veteran's PTSD. The Board has found nothing in the historical record which would lead to the conclusion that the most current evidence of record is not adequate for rating purposes. Moreover, the case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to that disability. Service connection for PTSD was granted by rating decision of May 1989, and was initially evaluated as 30 percent disabling. The veteran has no other service-connected disabilities. He has also been diagnosed with a nonservice- connected passive-aggressive personality [disorder] and alcohol dependence. In March 1996, the veteran claimed entitlement to a rating in excess of 30 percent for PTSD, alleging that such disability had increased in severity. In support of his claim, he enclosed written statements from himself and his spouse, both of which called attention to the severity of his current symptoms, and cited matters more fully set out above in the veteran's contentions. In May 1996, the veteran filed a claim for a total disability rating based on unemployability due to service-connected disability (VA Form 21-8940). He stated that he could not remember when he last worked. Other evidence included a hospital summary from The King's Daughters' Medical Center, a private medical facility, dated in January 1993, showing that the veteran was admitted after asking a policeman to shoot him because he wanted to die. His blood alcohol level on admission was 294[sic]. He complained of depression and nightmares about Vietnam, and was noted to have a long history of mental illness. He was initially socially withdrawn, with restricted mood and affect, but improved with treatment. The diagnoses at hospital discharge included major depression, severe with psychotic features; PTSD; and alcohol abuse, continuous. In addition, the veteran submitted copies of VA outpatient treatment records from the VAMC, Huntington, dated from July 1993 to December 1995. Those records reflect ongoing treatment of the veteran for PTSD, alcohol dependence, and depression. On one occasion the veteran stated that he has intermittent periods of depression; that he has fleeting thoughts of suicide, but will not kill himself; that his PTSD symptoms are not as bad in the winter time; that he has a difficult time working as they put too much pressure on him; that he is still uncertain about taking medication; and that he continues to drink alcohol amounting to a 12-pack of beer two or three times a week. Another entry noted that, on substance abuse screening, the veteran stated that he had undergone prior substance abuse treatment at Clarksburg, but had gotten drunk as soon as he was discharged. He related a history of six to eight driving-while-intoxicated charges, and two arrests for public drunkenness. He denied having a drinking problem, stated that he could stop drinking, and denied the need for detoxification or any type of therapy or rehabilitation. It was noted on several occasions that the veteran appeared to be in denial concerning his alcohol consumption and the effect that it was having on his life. The VA outpatient treatment records show that the veteran ultimately entered the Substance Abuse Treatment Program (SATP). During that period, he agreed to take Zoloft, 100 mgs. daily. Upon completion of the primary SATP, he entered the after-care program, but declined to attend AA. It was shown that his alcohol dependence was in remission. Four months later the veteran reported having drunk a six-pack of beer because he started feeling "electrical shocks all over his body." He reported that he was hospitalized overnight and was found to have an electrolyte imbalance. A report of VA psychiatric examination, conducted in December 1995, shows that the veteran had been hospitalized several weeks previously due to his electrolytes being low. He was currently prescribed Zoloft, Magnesium, Thiamine, Folic acid, and Benadryl. The veteran stated that he had not worked in three to four years because he cannot handle being around people. He reported previous employment working in a restaurant, in a welding shop for six to seven years, driving a truck, as a maintenance worker in an apartment complex, and working for a company that made windows and doors. He reported nightmares two to four times a month, difficulty falling asleep and staying asleep, and staying home most of the time because people bother him, as well as feeling lost, having no plans for the future, and having difficulty concentrating and remembering things. Mental status examination disclosed that the veteran's mood was depressed, with a restricted affect appropriate to his mood. His appetite was reported as fair, and insight and judgment were fair. The remainder of his mental status examination was within normal limits, and he was competent to handle benefits. The Axis I diagnoses were: PTSD; alcohol dependence, in remission; and depressive disorder, not otherwise specified. No Global Assessment of Functioning (GAF) score was provided, and no information was provided as to the veteran's current capability for gainful employment. VA outpatient treatment records from the VAMC, Huntington, dated from December 1995 to February 1997, show that the veteran continued to attend the PTSD/SATP aftercare group. In May 1996, it was shown that his alcohol dependence was in remission. In June 1996, it was reported that his medical doctor had stopped his Zoloft because of fears that it was increasing his blood pressure. He reported no alcohol or substance abuse, and his mood and affect were within normal limits. In August 1996, he reported continued abstinence. In October and November 1996, he continued to attend the PTSD/SATP aftercare group, and continued to carry diagnoses of PTSD and alcohol dependence, in remission. Records dated in January 1997 show that he was to report his plan for receiving continued support for his PTSD. An entry dated in February 1997 shows that he attended his last session in the aftercare group. He indicated that he did not wish a referral for PTSD counseling, stating that if he felt that he was going to relapse or wanted to talk about his PTSD symptoms, he would come back to the group. No other follow- up appointments were made. The diagnoses were alcohol dependence, in remission, and PTSD. In June 1997, the veteran submitted lay statements from his spouse and another member of his family offering their observations and conclusions concerning his mental status and behavior. A personal hearing was held before a Hearing Officer at the RO in June 1997. The veteran testified, in pertinent part, that he stays at home, dozes, and watches television; that he is depressed all the time and avoids crowds; that he doesn't take his medications because of his blood pressure problems; that his grandchildren make him nervous; that he has dreams two or three times a week and has brief flashbacks; that he gets only two or three hours sleep per night; that he does not attend church or get involved with his family, his neighbors, or the PTA; and that he has suicidal ideation and memory loss. His spouse offered her testimony in support of the veteran's contentions and arguments, particularly with respect to his violence, poor relationship with his family, and an episode in which he attempted suicide. A transcript of the testimony is of record. A report of private psychiatric examination by Dick C. Barumbe, MD, conducted in July 1997, shows that the veteran stated that he had a claim for PTSD and needed an evaluation. He further stated that he cannot sleep; that he is nervous and irritable; and that he gets mad easily. He admitted to having had suicidal thoughts two or three times, and stated that he doesn't want to be around people. He denied auditory or visual hallucinations, or abuse of alcohol or drugs. Mental status examination revealed that his appearance was cooperative, anxious, apathetic, and depressed, while his behavior was appropriate, relaxed and agitated. His speech was spontaneous, and his mood was depressed and his affect flat. The diagnosis was PTSD. A report of VA psychiatric examination, conducted in November 1997, shows that the examiner reviewed the veteran's claims folder and medical records. It was noted that a longitudinal review of the veteran's medical records revealed psychiatric diagnoses which included passive-aggressive personality with antisocial features; PTSD; PTSD, rule out major affective disorder; major affective illness; depression; alcohol abuse; alcohol dependence; major depression, severe, recurrent, with psychotic features; and a depressive disorder. It was noted that in January 1989, his Global Assessment of Functioning (GAF) score had been estimated as 50, with a past-year score of 60. The veteran related that he was married and had a 14-year old son; that he had been unemployed for about seven years; that he is in receipt of Social Security disability benefits; that he holds a valid driver's license; and that he spends his time sitting in his house watching television and taking care of his activities of daily living. He denied hobbies or interests; claimed that he could not concentrate long enough to participate in any activity; and asserted that he cut the grass two or three times a year. He asserted that when he tried to rely on people, he became anxious, extremely fearful and had urges to get away. He stated that when he accompanies his wife grocery shopping, he waits in the car, and hurries back from the post office as fast as possible. He claimed anhedonia, social isolation, significant social impairment, inability to get along with his wife, his grandchildren, and others, depression, sleep disturbances, nightmares with military content two or three times a week, a startle reaction, and daily intrusive memories of Vietnam experiences. The veteran stated that: "I am not drinking for the last two years. I am not saying that I quit, I am saying that I am not drinking." He then admitted that he has had short relapses during which he drank a 12-pack of beer on two occasions in the last year. His reported last use of alcohol was in August 1997, three months prior to the examination. Mental status examination disclosed that the veteran's mood was dysphoric; that he occasionally became tearful when describing his experiences in the military; and that he claimed constant suicidal thoughts without intent. The examiner offered the opinion that he had significant levels of anxiety, social isolation, avoidance of Vietnam-related stimuli, diminished interest in activities, and marked interpersonal deficits. However, the examiner further noted that the veteran was clean and fairly groomed; that his behavior was cooperative; that his affect was appropriate; that his speech was soft and coherent; that his thoughts were goal-directed; that his cognitive functions were preserved; that he denied visual or auditory hallucinations, that he denied first rank Schneiderian symptoms; and that he was competent to handle funds. The psychiatric examiner indicated that the veteran presented with significant levels of anxiety, social isolation, avoidance of stimuli that reminded him of traumatic events, and marked interpersonal deficits. The diagnoses included PTSD, chronic; alcohol dependence, in partial remission; and depression, not otherwise specified. Psychosocial stressors were reported to include PTSD symptoms, mood symptoms, and interpersonal stressors. His GAF score was currently 50, with a past-year score of 52. Medical and other evidence obtained from the Social Security Administration (SSA) in January 1998 shows that the veteran was granted SSA disability benefits in December 1991 due to mood disorders and anxiety disorders. A rating decision of January 1998 increased the evaluation for the veteran's service-connected PTSD from 30 percent to 50 percent disabling, effective March 26, 1996, the date of his reopened claim for increase, and continued the denial of his claim for a total disability rating based on unemployability due to service-connected disability. Analysis Evaluation of Service-Connected PTSD Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Separate diagnostic codes identify the various disabilities. The evaluation of service-connected mental disorders is currently based upon the resulting occupational and impairment under 38 C.F.R. Part 4,§ 4.125- 4.130 (1996, as amended). Where entitlement to service connection has already been established, and an increase in the disability rating is the issue, the present level of the disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). When evaluating a mental disorder, the rating agency considers the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during the periods of remission. An evaluation is assigned based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. The rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (1999). 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 required for the rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). Pursuant to Karnas v. Derwinski, 1 Vet. App. 308 (1991), where a law or regulation changes after the claim has been filed or reopened before administrative or judicial review has been concluded, the version most favorable to the veteran applies unless Congress provided otherwise or permitted the VA Secretary to do otherwise and the Secretary did so. This veteran has appealed the rating decision of August 1996 which denied entitlement to a rating in excess of 30 percent for PTSD, and now seeks a rating in excess of the currently assigned 50 percent evaluation, and well as a total disability rating based on unemployability, as discussed in the Introduction section of this decision, above. Effective November 7, 1996, VA revised the criteria for diagnosing and evaluating psychiatric disabilities. 61 Fed. Reg. 52,695 (1996, et. seq.). On and after that date, all diagnoses of mental disorders for VA purposes must conform to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 61 Fed Reg. 52,700 (1996), now codified at 38 C.F.R. §§ 4.125-4.130). The new criteria for evaluating service-connected psychiatric disability, including PTSD, are codified at newly designated 38 C.F.R. § 4.130. 61 Fed. Reg. 52,700-1 (1996). The new rating criteria are sufficiently different from those in effect prior to November 7, 1996, that the RO and the Board are required to evaluate the veteran's service-connected PTSD by applying the criteria contained in the VA Schedule for Rating Disabilities related to psychiatric disability as it was in effect prior to November 7, 1996, as well in accordance with the revised criteria that became effective on that date. Karnas, at 311. The record shows that the RO has done so. VA's Schedule for Rating Disabilities in effect prior to November 7, 1996 provides that the evaluation of psychoneurotic disorders, including PTSD, is based upon a General Rating Formula for Psychoneurotic Disorders codified under 38 C.F.R. Part 4, § 4.132 (1996). Under those criteria, a 30 percent evaluation was assignable when the PTSD symptoms resulted in definite impairment in the ability to establish or maintain wholesome relationships with people, and resulted in such a reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment. A 50 percent evaluation for PTSD is warranted where the ability to establish or maintain effective or favorable relationships with people is considerably impaired and, by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment, while a 70 percent evaluation is warranted for PTSD where the ability to establish and maintain effective and favorable relationship with people is severely impaired, and the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain and retain employment. A 100 percent evaluation is warranted for PTSD where the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community; or 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 result in profound retreat from mature behavior, or the claimant is demonstrably unable to obtain or retain employment. 38 C.F.R. Part 4, § 4.132, Diagnostic Code 9411 (1996). Effective November 7, 1996, mental disorders, such as PTSD, are assigned disability ratings based on a General Rating Formula for Mental Disorders described at 38 C.F.R. Part 4, § 4.130 (1999). That formula provides that mental disorders resulting in 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), will be assigned a 30 percent disability rating. 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 will be rated as 50 percent disabling. Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms such 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 will be rated as 70 percent disabling. 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 will be rated as 100 percent disabling. 38 C.F.R. Part 4, § 4.130, Diagnostic Code 9411 (1999). While the veteran's appeal was pending, the formula for evaluating PTSD changed, as described above. Following VA psychiatric examination in November 1997, the RO re-evaluated the veteran's case under both the old and the new criteria and determined that a 50 percent disability rating was appropriate given the veteran's symptomatology, effective March 25, 1996, the date of receipt of the veteran's reopened claim. In cases such as this, where the claim for an increased rating was filed prior to November 7, 1996, the Board also considers both the old and new rating formulas for evaluation of acquired psychiatric disorders, including PTSD, and applies the formula which is most favorable to the veteran's case. Karnas, at 311. The record in this case shows that the veteran has been variously diagnosed with psychiatric disorders which include PTSD; alcohol dependence; a passive-aggressive personality with antisocial features; PTSD, rule out major affective disorder; major affective illness; depression; major depression, severe, recurrent, with psychotic features; a depressive disorder; and, more recently, PTSD and alcohol dependence in partial, remission. The veteran's PTSD is currently rated as 50 percent disabling under 38 C.F.R. Part 4, § 4.130, Diagnostic Code 9411 (1999). In evaluating the veteran's disability due to his service-connected PTSD, the Board may not consider disability or impairment resulting from the veteran's nonservice-connected alcohol dependence, which is the product of his own willful misconduct. 38 C.F.R. § 3.301(c)(2) (1999). The record in this case shows that on VA psychiatric examination in December 1995, the veteran offered a symptom report which included being unable to handle being around people, of having nightmares two to four times a month, of difficulty falling asleep and staying asleep, and of staying home most of the time because people bothered him. He further stated that he had not worked in three to four years because he could not handle being around people. Mental status examination showed that his mood was depressed; that he had a restricted affect; and that his insight and judgment were fair. However, the psychiatric examiner found that the veteran was well-oriented, with relevant and coherent speech, intelligence in the average range, and intact recent and remote memory. He denied hallucinations or delusions, suicidal or homicidal ideations, and his mental status examination was otherwise within normal limits. Further, records of VA outpatient treatment from July 1993 to February 1997 show that the veteran's primary treatment was for his nonservice-connected alcoholism rather than for other psychiatric disability, and that the diagnoses included alcohol dependence, depression, and PTSD. In fact, the record shows that for an extended period, PTSD was diagnosed only by history. The report of private psychiatric evaluation in July 1997 does not show any treatment of the veteran; rather, it shows that he sought an evaluation solely because he had a pending claim for benefits based on PTSD and needed an evaluation. That report cites the veteran's symptomatic complaints, and reports that the veteran was anxious, apathetic, and depressed; that his behavior was appropriate, relaxed and agitated[sic]; and that his mood was depressed and his affect flat. The Board further notes that the report of VA psychiatric examination in November 1997 cited the veteran's symptom report, and that the mental status examination disclosed that the veteran's mood was dysphoric, that he occasionally became tearful when describing his experiences in the military; and that he claimed constant suicidal thoughts without intent. The examiner further noted that the veteran was clean and fairly groomed; that his behavior was cooperative; that his affect was appropriate; that his speech was soft and coherent; that his thoughts were goal-directed; that his cognitive functions were preserved; that he denied visual or auditory hallucinations, that he denied first rank Schneiderian symptoms; and that he was competent to handle funds. However, the Board notes that the veteran and his spouse have testified that he has no friends and no social life; that he has not worked in years; and that a major portion of his psychiatric impairment is social in nature and results in his having no friends and very few contacts other than his immediate family. The Board finds that testimony to be credible and substantiated by current medical evidence contained in the record. Furthermore, the psychiatric examiner concluded his report by offering the opinion that the veteran had significant levels of anxiety, social isolation, avoidance of Vietnam-related stimuli, diminished interest in activities, and marked interpersonal deficits. As previously noted, a rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (1999). To the same point, the veteran's GAF score was currently 50, with a past-year score of 52. The current score is indicative of serious symptoms, or serious impairment in social, occupational, or school functioning. While the past-year GAF score of 52 is consistent with moderate symptoms, or moderate difficulty in social, occupational, or school functioning, the Board again notes that where entitlement to service connection has already been established, and an increase in the disability rating is the issue, the present level of the disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Although a GAF score considers social and occupational functioning on a continuum of mental health-illness, and includes all psychiatric disability, including the veteran's nonservice-connected psychiatric symptomatology such as that stemming from his personality disorder and from his alcohol dependence in "partial" remission, the Board is precluded from differentiating between the symptomatology attributable to a nonservice-connected disability and that attributable to a service-connected disability in the absence of medical evidence making such distinction. See Mittleider v. West, 11 Vet. App. 181 (1998) In this case, neither the VA psychiatric examiners in December 1995 and in November 1997, nor the private psychiatrist in February 1997, differentiated between the social and occupational impairment stemming from the veteran's service-connected PTSD and any other psychiatric or psychosocial disabilities found present. In addition, the VA psychiatric examiner concluded his report by offering the opinion that the veteran had significant levels of anxiety, social isolation, avoidance of Vietnam- related stimuli, diminished interest in activities, and marked interpersonal deficits (emphasis added). Under the criteria for rating mental disorders prior to November 7, 1996, a 100 percent evaluation is warranted for PTSD where the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. A 100 percent evaluation is also warranted where the claimant is demonstrably unable to obtain or retain employment. 38 C.F.R. Part 4, § 4.132, Diagnostic Code 9411 (prior to November 7l, 1996). The record in this case presents no credible evidence that the veteran has any contacts at all outside his home. Furthermore, the newly revised criteria for evaluating mental disorders, effective on and after November 7, 1996, provides that a 100 percent evaluation will be assigned where there is total occupational and social impairment due to such symptoms as: gross impairment in communication. 38 C.F.R. Part 4, § 4.130, Diagnostic Code 9411 (1999). The Board is satisfied that the medical evidence of record, together with the testimony of the veteran and his spouse, is sufficient to show that the veteran is virtually isolated in the community. The Board further finds that the veteran's PTSD symptomatology results in such symptoms as gross impairment in communication, not only with prospective employers, but with members of his immediate family. In addition, the medical records obtained from the Social Security Administration show the veteran to be totally disabled due to mood disorders and anxiety disorders since 1991, and the Board finds no basis upon which to differentiate the diagnosed mood disorders and anxiety disorders from the veteran's service-connected PTSD. The Board further finds that that the severity of his PTSD symptomatology is such as to warrant assignment of an increased schedular evaluation for PTSD, based upon the criteria in effect both prior to and on and after November 7, 1996. The Board has carefully considered the veteran's claim for a rating in excess of 50 percent for his service-connected PTSD under both the old and the new criteria for evaluating psychiatric disability, and finds that application of either the old or the newly-revised criteria for rating mental disorders would result in the assignment of a schedular 100 percent disability evaluation in the captioned matter when the additional testimony offered and the Social Security Administration determination and medical records are taken into consideration. While the RO determined that application of the newly-revised criteria would be in the veteran's favor, yielding an increased rating of 50 percent from March 25, 1996, the date of his reopened claim for increase, the Board concludes, based upon the evidence and for the reasons set forth above, that the clinical and other data establish that the veteran's service-connected PTSD is currently productive of virtual isolation in the community; that the veteran's PTSD symptomatology results in such symptoms as gross impairment in communication with members of his own family, as well as with prospective employers; and that the severity of his PTSD symptomatology is alone sufficient to render him effectively incapable of securing and retaining substantially gainful employment. It addition, the Board finds that such impairment has existed continuously since the date of filing of his reopened claim. In reaching its decision, the Board has considered the doctrine of reasonable doubt. In this case, as the preponderance of the evidence clearly favors the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An increased schedular rating of 100 percent for PTSD is granted, subject to controlling regulations governing the payment of monetary benefits. F. JUDGE FLOWERS Member, Board of Veterans' Appeals