Citation Nr: 0002578 Decision Date: 02/02/00 Archive Date: 02/10/00 DOCKET NO. 97-29 252 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE The propriety of the initial 30 percent rating schedular rating assigned for the veteran's service-connected post- traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Steven D. Reiss, Counsel INTRODUCTION The veteran served on active duty from April 1965 to February 1969, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York, which granted service connection for PTSD and assigned an initial 30 percent evaluation for the disability, effective January 11, 1994. The veteran timely appealed the assigned rating to the Board. Because the veteran has disagreed with the initial rating assigned for his PTSD, the Board has recharacterized the issue as involving the propriety of the initial evaluation assigned, in light of the recent decision of the United States Court of Veterans Appeals (now known as United States Court of Appeals for Veterans Claims) (Court) in Fenderson v. West, 12 Vet. App. 119, 126 (1999). In June 1999, the veteran, accompanied by his accredited representative, presented testimony to the undersigned Board Member at a hearing held in Washington, DC. At the hearing, the undersigned Board Member granted the veteran's request to hold the record open for thirty days for the submission of pertinent evidence. Six weeks later, the veteran submitted, accompanied by a waiver of RO consideration, VA medical records, dated from September 1998 to March 1999, including a January 1999 VA hospitalization report, reflecting treatment for his PTSD. Although submitted more than thirty days subsequent to the veteran's Board hearing, because records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, see Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992), this evidence will be considered by the Board in connection with the instant appeal. As a final point, the Board observes that, in written argument dated in June 1999, the veteran's representative contended that, if a total schedular rating for PTSD were not established, the veteran was informally asserting a claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). In view of the Board's action in this case (in which a 100 percent schedular evaluation is deemed warranted for some, but not all, of the period under consideration), the matter of the veteran's entitlement to TDIU is referred to the RO for appropriate action. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained. 2. During the period from January 11, 1994, to June 4, 1997, the veteran's PTSD was manifested by frequent nightmares; flashbacks; chronic sleep impairment; intrusive thoughts; irritability; impaired memory, concentration and impulse control, with periods of violent behavior; depression; anxiety; panic attacks; survivor guilt; an exaggerated startle response; difficulty adapting to stressful situations; homicidal ideation; some neglect of personal appearance and hygiene; and some social isolation. 3. Since June 5, 1997, the veteran's severe PTSD has been objectively shown to render him unemployable. CONCLUSION OF LAW 1. The criteria for an initial schedular evaluation of 70 percent for PTSD, from January 11, 1994 to June 4, 1997, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.16(c), 4.130, 4.132, Diagnostic Code 9411 (1996 & 1999). 2. The criteria for the assignment of a 100 percent schedular evaluation for PTSD, since June 5, 1997, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.16(c), 4.130, 4.132, Diagnostic Code 9411 (1996 & 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim regarding the propriety of the initial 30 percent evaluation assigned for his service-connected PTSD is plausible and capable of substantiation and is therefore well grounded within the meaning of 38 U.S.C.A. § 5107(a); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). When a claimant submits a well-grounded claim, VA must assist him in developing facts pertinent to the claim. Id. The Board is satisfied that all available relevant evidence has been obtained regarding the claim and that no further assistance to the veteran is required to comply with 38 U.S.C.A. § 5107(a). Background In December 1992, the RO received the veteran's application to reopen a claim for service connection for PTSD. As noted above, in a July 1997 rating action, the RO granted service connection for PTSD and assigned a 30 percent evaluation, effective January 11, 1994, the date of the grant of service connection. In addition, in October 1998, the RO granted entitlement to a temporary total evaluation from April 3 to April 28, 1995, pursuant to 38 C.F.R. § 4.29, which reflects that, during that period, he was hospitalized to treat his PTSD. In support of this claim, the veteran submitted to the RO a copy of a March 1988 decision of the Social Security Administration (SSA) that established his entitlement to disability benefits from that agency, effective June 30, 1986. The SSA determination reflects that he was found to be unable to work due to PTSD, alcohol abuse and a personality disorder. In addition, he submitted copies of records that were considered by the SSA reflecting VA treatment for the disability, which is duplicative of records that were already in the claims folder; he also submitted the report of an October 1987 examination that was conducted in conjunction with the claim, and which reflects that he was diagnosed as having PTSD and chronic alcoholism. Also of record are pertinent VA medical records, dated from February 1993 to April 1995, including July 1994 and April 1995 VA hospitalization reports. Entries dated from February to April 1993 show that he complained of having flashbacks and nightmares, that he was unable to sleep for extended periods. He also consistently presented himself with poor personal hygiene; in April 1993, the VA psychiatrist, who had treated the veteran since 1985, commented that, "he is wearing the same clothes for seven days and it shows." In addition, a January 1994 entry, his treating psychiatrist noted that the veteran complained that, although Valium was helping treat his PTSD, he was still not able to sleep for more than three to four hours a night. In a subsequent entry, apparently dated in May 1994, the VA physician noted that the veteran complained of having nightmares and intrusive thoughts concerning his experiences in Vietnam and indicated that, with the exception of "occasional painting for friends," he had not been employed for approximately ten years. In addition, the psychiatrist reported that the veteran had problems with relationships and that he easily became bored. A June 1994 entry reflects that the veteran's regular treating psychiatrist reported that the veteran was unkempt and that he smelled of alcohol, mustiness and "something more unpleasant." The veteran further reported that he did not keep in touch with his brother, father or sister, although he did maintain a relationship with his son. The veteran was hospitalized for his psychiatric problems from July 17 to July 20, 1994. According to the hospitalization report, the veteran became "actively, acutely intoxicated" on July 17 and indicated that he had flashbacks of his Vietnam experiences. He stated that he felt "uncontrolled rage" and was capable of hurting himself and others. The physician noted that the veteran had a history of assaultive behavior when he was intoxicated. A mental status examination disclosed that the veteran was alert and oriented and that his speech was coherent. In addition, it revealed that the veteran denied having delusions or hallucinations as well as current homicidal or suicidal ideation; he also denied having a history of prior suicide attempts. The physician indicated, however, that the results also disclosed that the veteran was "preoccupied" with his PTSD and that he had "limited" insight and judgment. He added that the treatment was terminated when the veteran "decided all of a sudden to leave the hospital." The Axis I diagnoses were PTSD, dysthymia and alcohol abuse, and on Axis V, the physician reported "moderately severe symptoms," but no Global Assessment of Functioning (GAF) Scale score was offered. In September 1994, the veteran's treating psychiatrist reported that his appearance was "still" unkempt, although she indicated that he was clean. In addition, in January 1995, his treating psychiatrist noted that he reported having played "Russian Roulette" and that he had shot himself in the right forehead. A subsequent January 1995 outpatient treatment entry shows that the veteran reported that he had not slept for several days. The entry further reflects that a VA examiner described the veteran as alert, anxious and oriented, and diagnosed him as having PTSD, ethanol abuse and a personality disorder, not otherwise specified. In addition, a mental status evaluation conducted that same month revealed that the veteran was alert and oriented and that he appeared to be in good contact with reality. In addition, the veteran denied having hallucinations or delusions as well as any current suicidal or homicidal ideations. The examiner, however, described the veteran's affect as "tired" and his speech as "slow, deliberate and slurred" and indicated that his insight and judgment were poor. The diagnoses were rule out PTSD, a personality disorder not otherwise specified and alcohol abuse. In addition, the examiner recommended that the veteran be referred for outpatient treatment care for his PTSD as well as for inpatient treatment. Thereafter, in March 1995, his treating VA psychiatrist reported the veteran "looked scruffy again." The April 1995 hospitalization report shows that the veteran was hospitalized to treat his PTSD from April 3 to April 28, 1995. The report reflects that the veteran complained that he wanted to care about things, but was unable to and that he was apathetic about life. In addition, the veteran stated that he "goes off," which he explained led to becoming inebriated or going to the hospital for treatment. In addition, he reported that he took unnecessary risks, such as walking in dangerous parts of town. The veteran further indicated that he formerly treated his psychiatric problems with Elavil and Ativan, but that he was currently treating the disability with Valium. The veteran also indicated that he had a history of assaultive behavior, and stated that he had been involved in a fight approximately one month earlier. A mental status examination administered at admission disclosed that the veteran exhibited no obvious motor restlessness, was oriented to self, others, place and time, and that he had no clear depressive symptoms. In addition, his memory, insight and judgment were described as good. During the hospitalization, the veteran actively participated in all phases of the inpatient PTSD treatment program. The physician reported, however, that the veteran's feelings of alienation led to overall demotivation and the loss of interest in activities that he had previously found to be meaningful. In addition, with respect to his social impairment, the physician stated that the veteran had lost his family as a consequence of his PTSD. The prognosis at discharge was "fair, given the severity of his condition." In addition, the physician recommended that the veteran outpatient treatment by his treating psychiatrist. The diagnoses at discharge were severe, chronic PTSD; and alcohol dependence, which the physician indicated was "probably secondary" to his PTSD; no GAF score was offered. VA outpatient treatment records, dated from May 1995 to October 1996, show that the veteran was regularly seen by his treating psychiatrist for various complaints related to his PTSD and alcoholism, including nightmares, flashbacks, intrusive thoughts, and chronic sleep impairment. Among these records is a June 1995 entry, which reflects that the veteran received treatment subsequent to a particularly troubling flashback. The entries also indicate that the psychiatrist repeatedly described the veteran's appearance as "scruffy." Also of record is a June 1997 VA Social Work Survey report. The report reflects that the survey was conducted at the RO's request in connection with his claim for service connection for PTSD. The veteran was interviewed in May and June 1997. After discussing in detail the veteran's military and post- service history, the examiner indicated that it was his impression that the veteran's adjustment from military life had been "marginal at best." He reported that the veteran had several relationships with women and that he was unable to sustain them due to his PTSD. In addition, the examiner stated that the veteran was "unable to maintain or sustain a job" due to his PTSD. Further, he reported that, even when employed, the veteran had disagreements with any employer who attempted to place restrictions on his freedom of movement. He also stated that the veteran tended to isolate himself on the job. In addition, the examiner indicated that he did not socialize with any of his coworkers, either on or off the job. Moreover, with respect to the veteran's award of disability benefits from the SSA, the examiner stated that the award was primarily based on his PTSD. As a final point, he said that, in his professional opinion, the veteran suffered from PTSD that "totally incapacitates" him from working "in any gainful way." In July 1997, the veteran underwent a VA psychiatric examination, also in connection with his claim for service connection for this disability. At the outset of the report, the examiner indicated that he had reviewed the veteran's claims folder and discussed the veteran's military and post- service psychiatric and employment history. In addition, he observed that the veteran was receiving regular care from his treating VA psychiatrist, who had been treating him since 1985. The examiner also observed that the veteran was treating his PTSD with Valium. During the examination, the veteran reported that, at night, he had nightmares and has difficulty sleeping. He stated that he walked around carrying a knife and that he would use it to kill anyone who attempted to break into his home. In addition, the veteran said that he was hypervigilant, and that numerous environmental conditions precipitated the onset of flashbacks and intrusive thoughts. The evaluation revealed that the veteran was oriented to time, place and person and that he was relevant, coherent and cooperative. The examiner indicated that the veteran exhibited memory problems but that the impairment was not severe. In addition, the veteran denied having delusions or hallucinations, but reported having flashbacks, nightmares and a desire to kill people; however, he denied having suicidal ideation. The examiner indicated that the veteran's affect was flat and that his speech was circumstantial. The diagnoses were chronic, delayed PTSD and history of alcohol abuse. In addition, the examiner estimated his GAF score was "around" 52. Further, after offering the diagnoses and GAF score, the examiner noted that veteran's psychiatric symptoms and stated that he had not been able to work since 1987. In December 1996, the veteran testified at a hearing before a hearing officer in support of his claim for service connection for PTSD. During that hearing, the veteran primarily discussed his in-service stressful experiences. Thereafter, in November 1997, after service connection for PTSD had been established, the veteran was afforded another hearing before a hearing officer at the RO. During the latter RO hearing, in connection with his claim for a higher rating for his PTSD, the veteran testified that he suffered from chronic sleep impairment and that he never slept more than three to four hours a night, and not more than "two hours straight." He also reported that he thought about his Vietnam experiences daily and that doing so interfered with his activities. In addition, the veteran stated that he was recently suffering from an increased number of flashbacks since moving to his current home, which was located near a military facility. With respect to his social impairment, the veteran reported that he was "totally ostracized" from his family, and that, with the exception of his son, had not seen any one for approximately eight years. He further testified that he was treating his PTSD with Valium, and that he had been seeing the same VA psychiatrist on a weekly basis for treatment of the disability for approximately eight to ten years. The veteran reported that, in addition to the flashbacks, his PTSD was productive of intrusive thoughts, anxiety attacks, nervousness, depression, "hyperalertness," chronic sleep disturbance, survivor's guilt, anger, rage and distrust of authority. Additional VA outpatient treatment records, dated from November 1996 to September 1998, show that the veteran continued to receive regular treatment for various complaints related to his PTSD. In a June 1997 entry, his treating psychiatrist noted his continued symptomatology and reported that he avoided all others except for other Vietnam veterans. In addition, the examiner reported that the veteran had had "a marginal lifestyle" for more than ten years. In an entry dated later that same month, the psychiatrist observed that the veteran had recently been interviewed for four hours as part of a VA social survey. In January 1998, the psychiatrist noted the veteran's continuing relationship problems, which included problems with authority figures and an inability to trust others. In February 1998, the examiner reported that the veteran was reclusive and had few friends and described him as "living on the fringes of society." In addition, in June 1998, she indicated that despite his regular treatment, he was resistant to change. The veteran's treating psychiatrist apparently retired shortly thereafter, and in a September 1998 entry made by his new treating VA psychiatrist, that physician reported that the veteran's twelve-year common law relationship had ended due to his PTSD. In addition, he stated that he was disabled due to this disability for approximately ten years, and that as a consequence of his PTSD, he was not able to get along with others, had nightmares every night and had problems with his temper. As noted in the introduction to this decision, after his June 1999 hearing, the veteran submitted pertinent VA medical records, dated from September 1998 to March 1999. The outpatient treatment records show that the veteran continued to suffer from various psychiatric symptoms due to his PTSD, such as nightmares, social isolation, irritability, and anxiety. In addition, in a March 1999 entry, the veteran recounted an incident when, during a flashback, he "lost control" and gave his son "a chop to the neck" that almost killed him. Among the records submitted was a January 1999 VA hospitalization report, which indicates that he was hospitalized from December 29, 1998, to January 1, 1999, to treat his psychiatric problems. The January 1999 hospitalization report shows that, upon admission, he was diagnosed as having PTSD, alcohol abuse and antisocial personality traits. In addition, the physician indicated that he suffered from a lack of emotional and family support, and assigned a GAF score of 20. The report reflects that the veteran was brought to the VA hospital by "friends" because he was suicidal and homicidal; they noted that he had exited his home carrying a shotgun. The veteran acknowledged that he was homicidal "for months." During the hospitalization, the veteran reported that he was easily irritable and stated that he recently "almost killed two people." In addition, he reported that he shot at others a few years earlier but did not get caught. The veteran acknowledged that he had a "short fuse" and that he was violent. Further, he said that he kept a knife at his bedside for protection against intruders. He also reported that he ran out of Valium approximately one month ago, and that he had not slept in three days. A mental status examination administered during the hospitalization disclosed that the veteran was awake, alert and able to carry out activities of daily living. His posture, however was described as stiff, and the physician characterized him as "detached and aloof." The physician indicated that his affect was "limited" and that his mood was agitated and angry; he noted that the veteran responded to questions with brief answers. In addition, the physician reported that, during the hospitalization, the veteran was placed on a suicide watch. The report reflects that the veteran was discharged in stable condition and instructed to take the prescribed psychiatric medications and to return for further VA outpatient treatment; a GAF score at discharge was not assigned. During the June 1999 hearing, the veteran testified that his PTSD had worsened during the past two years, that he was currently having flashbacks at least five to six times per week, and that numerous auditory and olfactory phenomena triggered the flashbacks of his Vietnam experiences. He also reported that, during such times, he "shuts down," and "freezes." The veteran further stated that he was placed on suicide watch the previous Christmas and was hospitalized at the Buffalo, New York, VA Medical Center. In addition, the veteran testified that, due to his nightmares, he was unable to sleep more than one hour at a time, and that he has gone for two to three days at a time without sleeping. The veteran explained that he is often afraid to sleep. He said that he does not feel safe at home when he does not have knifes near him and generally carries two on his person when he leaves home; one to throw and one to use. The veteran also reported suffering from uncontrollable anger and rage, and reported that he recently had "snapped" and almost killed his son. With regard to his social impairment, the veteran testified that he does not interact with people "at all" and that he normally just stays home and does not venture outside. He said that he reads quite a bit, and that when he goes walking, he does so in the woods and in graveyards because these places are one in which he will not encounter others. In addition, he reiterated that his son is the only member of his family with which he has any contact; in this regard, he reported that he no longer was in a relationship with the woman referred to above. The veteran further testified that he did not go to other people's homes or to church, that he did not participate in sports and that he preferred to be alone. He also stated that he had not worked on a full-time basis since 1986 or 1987, and had had no paid employment of any kind during the past two years. Finally, he acknowledged that he had a problem with alcohol, and noted that he was receiving regular treatment for his psychiatric problems at VA; he noted that he was taking Valium and Darvon to treat the disability. In addition, in numerous statements, the veteran essentially echoed the contentions voiced at the November 1997 and June 1999 personal hearings and asserted entitlement to a 100 percent rating for his PTSD. He maintained that the disability was productive of severe social and total industrial impairment. In doing so, he argued that he was found to be unemployable by the SSA in 1988 essentially due to his PTSD. Finally, in written argument, the veteran's representative noted that, effective November 7, 1996, VA had amended the criteria for evaluating psychiatric disabilities. He thereafter referenced the findings of the report June 1997 VA Social Survey, the entries in the VA outpatient treatment records and VA hospitalization reports and argued that the veteran's PTSD satisfied each of the three criteria required for a 100 percent evaluation under the former rating criteria; in doing so, he pointed out that, in Johnson v. Brown, 7 Vet. App. 95, 97 (1994), the Court held that each of the criteria constituted independent bases for granting a 100 percent disability evaluation. In addition, he contended that, in light of the Court's decision in Barela v. West, 11 Vet. App. 280, 283 (1998), the veteran's alcoholism should be considered part of his service-connected psychiatric disability and that the overall psychiatric impairment should be rated accordingly. The veteran representative further maintained that, under the revised rating criteria, a 100 percent schedular evaluation was likewise warranted. Alternatively, his representative argued that at least a 70 percent evaluation was justified, and that, pursuant to former section 38 C.F.R. § 4.16(c), which provided that where, as here, the veteran was unemployable due to his PTSD, the mental disorder must be assigned a 100 percent evaluation under Diagnostic Code 9411. Analysis Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (1999). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (1999). The veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1 (1998); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Before proceeding with its analysis of the veteran's claim, the Board finds that some discussion of the Fenderson case is warranted. In that case, the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case in which the veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. In the former case, the Court held in Francisco v. Brown, 7 Vet. App. 55, 58 (1994), that the current level of disability is of primary importance when assessing an increased rating claim. In the latter case, however, where, as here, the veteran has expressed dissatisfaction with the assignment of an initial rating, the Francisco rule does not apply; rather, the VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim - a practice known as "staged rating." In view of the Board's action, as explained below, a remand to consider "staged rating" is unnecessary. As noted above, effective November 7, 1996, VA revised the criteria for diagnosing and evaluating psychiatric disabilities, to include PTSD. 61 Fed. Reg. 52,695 (1996). Where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the veteran applies, absent congressional or Secretarial intent to the contrary. See Dudnick v. Brown, 10 Vet. App. 79 (1997); Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). As the RO has considered the claim under the former and revised criteria in its July 1997 rating action, a copy of which was provided to the veteran in the September 1997 Supplemental Statement of the Case (SSOC), there is no prejudice to the veteran in the Board doing likewise, and applying the more favorable result. The veteran's PTSD is rated as 30 percent disabling under Diagnostic Code 9411. Under the former criteria, a 30 percent evaluation required that the PTSD be productive of definite impairment of social and industrial adaptability. The term "definite" has been defined as "distinct, unambiguous, and moderately large in degree," representing a degree of social and industrial inadaptability that was "more than moderate but less than rather large." O.G.C. Prec. 9-93 (Nov. 9, 1993); see also Hood v. Brown, 4 Vet. App. 301 (1993). A 50 percent evaluation was assigned where the ability to establish or maintain effective or favorable relationships with people was considerably impaired and where the reliability, flexibility, and efficiency levels were so reduced by reason of psychoneurotic symptoms as to result in considerable industrial impairment. A 70 percent evaluation required that the ability to establish and maintain effective or favorable relationships was severely impaired and that the psychoneurotic symptoms were of such severity and persistence that there was severe impairment of the ability to obtain or retain employment. To warrant a 100 percent evaluation, the attitudes of all contacts except the most intimate must have been so adversely affected as to result in virtual isolation in the community; or there must have been totally incapacitating 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; or, as a result of the psychiatric disability, the individual must have been unable to obtain or retain employment. Further, as pointed out by the veteran's representative, the Court has held that such criteria provide three independent bases for granting a 100 percent disability evaluation. See Johnson v. Brown, 7 Vet. App. 94, 97 (1994). In addition, 38 C.F.R. § 4.16(c) (1996), which was repealed when the revised criteria for rating psychiatric disabilities became effective, provided that where the veteran's only compensable service-connected disability was a mental disorder that was assigned a 70 percent evaluation, and that mental disorder precluded a veteran from securing or following a substantially gainful occupation, the mental disorder must be assigned a 100 percent evaluation under the appropriate diagnostic code. Under the revised criteria, a 30 percent evaluation is warranted when the disorder is productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks on no more than a weekly basis, chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent evaluation is warranted when the disorder causes occupational and social impairment, with reduced reliability and productivity, due to such symptoms as flattened affect; circumstantial, circumulatory, or stereotyped speech; panic attacks more frequently than once per 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for 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. After a careful review of the record, the Board finds that, from January 11, 1994, the date service connection for PTSD was established, (and excluding a 1995 period of hospitalization for which the veteran reveived a temporary total evaluation), the level of impairment due to the veteran's service-connected PTSD most closely approximates the criteria for a 70 percent rating, under either the former, or, since November 7, 1996, the revised, applicable criteria. In reaching this determination, the Board observes that the July 1994 VA hospitalization report shows that the veteran was hospitalized for three days and that he reported that his PTSD was productive of flashbacks of his Vietnam experiences as well as "uncontrolled rage." In addition, he stated that he was capable of hurting himself and others. The report indicates, however, that he denied having delusions or hallucinations, as well as current homicidal or suicidal ideation, and a mental status examination disclosed that the veteran was alert and oriented and that his speech was coherent. In addition, the voluminous VA outpatient treatment records, dated prior to June 5, 1997, consistently show that the veteran suffered from frequent and disturbing nightmares, as well as flashbacks and chronic sleep impairment. Further, his treating psychiatrist reported that the disability was also manifested by intrusive thoughts, irritability, impaired memory, concentration and impulse control and periods of violent behavior. Those outpatient treatment entries further reflect that he sometimes neglected his personal appearance and hygiene and that he suffered from depression, anxiety, panic attacks, difficulty adapting to stressful situations and homicidal ideation. Moreover, his treating physician repeatedly observed that the only social relationships he was able to maintain was with his son and former girlfriend, and that he had no relationships with his brother, sister and father, reflecting social isolation. Indeed, this physician remarked that the veteran had a marginal existence and had lived on the fringes of society for many years. Overall, then, the evidence indicates that between the effective date of the grant of service connection, January 11, 1994, to June 4, 1997, the veteran's PTSD was manifested by frequent nightmares; flashbacks; chronic sleep impairment; intrusive thoughts; irritability; impaired memory, concentration and impulse control, with periods of violent behavior; depression; anxiety; panic attacks; survivor guilt; an exaggerated startle response; difficulty adapting to stressful situations; homicidal ideation; some neglect of personal appearance and hygiene; and some social isolation. The Board finds that these symptoms reflect severe impairment in his ability to both obtain and retain employment as well as his ability to establish and maintain effective or favorable relationships, warranting a 70 percent evaluation under the former regulations. Such symptoms likewise suggest, since November 7, 1996, occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment thinking or mood, so as to warrant a 70 percent evaluation under the revised regulations. While the veteran and his representative suggest that entitlement to the maximum evaluation is warranted, the medical evidence did not clearly reflect total occupational and social impairment prior to June 5, 1997, under either the former or revised applicable schedular criteria, to include the provisions of former section 4.16(c). Indeed, while the veteran was shown to suffer from both severe symptoms and limited social interaction, neither totally incapacitating symptomatology nor virtual isolation in the community was shown. Significantly, while the veteran has been in receipt of Social Security benefits since 1987, based, in part, upon his diagnosis of PTSD (along personality disorder and alcohol abuse, for which service connection has not been established) there is no objective evidence to establish that, prior to June 5, 1997, the veteran's PTSD, alone, was sufficiently incapacitating to result in unemployability. Similarly, while, after November 7, 1996, the record reflects some of the symptoms included in the criteria for the 100 percent evaluation under the revised criteria, such as memory loss and neglect of personal hygiene, such symptoms are not shown to be of the intensity and severity contemplated in the rating schedule. Significantly, other symptoms included among the criteria, such as gross impairment in thought processes, persistent delusions and hallucinations, grossly inappropriate behavior, and disorientation as to time or place, are simply not shown. Furthermore, the record does not present evidence (prior to June 5, 1997) of such factors as marked interference with employability (i.e., beyond that contemplated in the assigned evaluation), repeated hospitalizations due to PTSD, or evidence of other unusual or exceptional factors that rendered inadequate the regular schedular standards so as to warrant assignment of an evaluation higher than 70 percent on an extra-schedular basis during the period in question. See 38 C.F.R. § 3.321(b)(1). Significantly, however, in a June 5, 1997 report, a VA social worker who conducted a four-hour social and industrial survey of the veteran offered the opinion that the veteran was "unable to maintain or sustain a job" due to his PTSD, commenting that that PTSD, alone, "totally incapacitated" him from working "in any gainful way." The Board notes that the June 1997 represents the first objective indication that the veteran's PTSD rendered him demonstrably unable to obtain or retain employment, which would warrant a 100 percent schedular evaluation under the former rating criteria. See Johnson, 7 Vet. App. at 97. The Board also notes that there is no specific opinion of record to directly contradict that opinion. While a VA psychiatrist who examined the veteran in July 1997 assigned a Global Assessment of Functioning (GAF) score of 52 [ which, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV), reflects moderate symptoms and moderate difficulty in social and occupational or school functioning, he also noted the veteran's complaints that the disability was productive of flashbacks, nightmares, and a desire to kill people. Interestingly, while the psychiatrist indicated that he had reviewed the claims file, it does not appear that he had benefit of the report of the interview conducted a mere one month prior by a VA social worker; the psychiatrist did not render a specific assessment as to the extent that the veteran's PTSD impaired his ability to obtain or retain employment. The assignment of a 100 percent schedular evaluation from June 5, 1997 also appears to be consistent with other evidence of record. As discussed above, prior to June 1997, due to his PTSD, the veteran's ability to establish and maintain effective or favorable relationships with people was severely impaired. In this regard, the Board reiterates that, during that time, the evidence reflects that the veteran had "lost" his relationships with most of his family, i.e., his brother, sister and father, although he maintained one with his son and had a long-term relationship with his girlfriend. However, the evidence reflects that, in September 1998, his new treating VA physician reported that the veteran's twelve-year relationship with his girlfriend ended due to symptomatology attributable to his PTSD. In that same entry, his treating psychiatrist commented that the veteran reported having nightmares on a nightly basis. Moreover, with respect to his relationship with his son, in a March 1999 entry, that same psychiatrist noted that the veteran recounted an incident when, during a flashback, he "lost control" and almost killed his son. Furthermore, in the January 1999 hospitalization report, the physician indicated that, at admission, a physician assigned a GAF score of 20, which DSM-IV indicates that the individual is in some danger of hurting himself or others or a persistent inability to maintain personal hygiene or serious suicidal acts with a clear expectation of death; DSM-IV indicates that a GAF score of 31 to 40 reflects an inability to work. Moreover, the report states that the veteran was brought to the VA hospital by "friends" because he was suicidal and homicidal; they noted that he had exited his home carrying a shotgun. Indeed, the veteran acknowledged that he was homicidal "for months," reported that he recently "almost killed two people," and was placed on suicide watch. In addition, he reported that he shot at others a few years earlier but did not get caught. The social worker's report also is in harmony with the veteran's own testimony elicited during the pendency of the appeal. In November 1997, he reported that he was recently suffering from an increased number of flashbacks since moving to his current home, which was located near a military facility. Moreover, during his June 1999 hearing, the veteran testified that his PTSD had worsened during the past two years, i.e., since approximately June 1997, and that he was currently having flashbacks at least five to six times per week. He also stated that he was no longer in a relationship with his girlfriend due to his PTSD. Given the above, and with resolution of all reasonable doubt in the veteran's favor (see 38 U.S.C.A. § 5107(b)), the Board finds that, as of June 5, 1997, the criteria for a 100 percent schedular rating for the veteran's PTSD, under the criteria in effect prior to November 7, 1996, have been met. See Johnson, 7 Vet. App. at 97. As the veteran is deemed entitled to the maximum assignable evaluation under the former criteria, consideration of the revised criteria from this period is unnecessary. ORDER Subject to the law and regulations governing payment of monetary benefits, an initial 70 percent schedular rating for PTSD, from January 11, 1994, is granted. Subject to the law and regulations governing payment of monetary benefits, a 100 schedular percent rating for PTSD, from June 5, 1997, is granted. JACQUELINE E. MONROE Member, Board of Veterans' Appeals