Citation Nr: 1333853 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 07-09 879 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to increases in the "staged" ratings (of 30 percent prior to July 19, 2007, and 50 percent from that date) assigned for the Veteran's posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from May 1964 to May 1984. This matter is before the Board of Veterans' Appeals (Board) on remand from the United States Court of Appeals for Veterans Claims (Court). The case was originally before the Board on appeal from a May 2006 rating decision of the Waco, Texas Department of Veterans Affairs (VA) Regional Office (RO) that, in pertinent part, granted service connection for PTSD, rated 10 percent, effective November 15, 2005 (date of claim). In February 2007, the RO issued a rating decision that increased the rating for PTSD to 30 percent, effective November 15, 2005. In March 2010, the Board remanded the claim for additional development. Based on the development, in a November 2010 rating decision, the RO increased the rating for PTSD to 50 percent, effective July 19, 2007. [An August 2010 rating decision also assigned a 100 percent (temporary total for hospitalization) rating for the period from January 7, 2009 to March 1, 2009, and that period of time is not for consideration herein.] In a decision issued in August 2011, the Board upheld the 'staged' ratings (of 30 percent prior to July 19, 2007, and 50 percent from that date) assigned for the Veteran's PTSD. He appealed that decision to the Court. In March 2012, the Court vacated the August 2011 Board decision and remanded the matter for readjudication consistent with the instructions outlined in a February 2012 Joint Motion for Remand (Joint Motion) by the parties. In October 2012, the Board remanded this case for additional development and to ensure compliance with the directives of the Joint Motion. The record reflects that the Veteran was represented by an attorney before the Court, but that Vietnam Veterans of America continues to represent him before the Board. Finally, the Board notes that it has reviewed both the Veteran's physical claims file and "Virtual VA" (VA's electronic data storage system) to ensure that the complete record is considered. FINDINGS OF FACT 1. Prior to July 19, 2007, the Veteran's PTSD was not manifested by symptoms greater than productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; occupational and social impairment with reduced reliability and productivity due to PTSD symptoms was not shown. 2. From July 19, 2007, the Veteran's PTSD has been manifested by symptoms productive of impairment no greater than occupational and social impairment with reduced reliability and productivity; symptoms productive of occupational and social impairment with deficiencies in most areas are not shown. CONCLUSION OF LAW Ratings for PTSD in excess of 30 percent prior to July 19, 2007 or in excess of 50 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1-4.7, 4.21, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). As the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). A February 2007 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased initial rating, and an August 2010 supplemental SOC readjudicated the matter after the Veteran and his representative responded and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("where a claim has been substantiated after the enactment of the VCAA, the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). The Veteran's pertinent treatment records have been secured. He was afforded VA examinations in May 2006, October 2007, June 2010, and April 2013; those examinations are reported in greater detail below, and are cumulatively adequate for rating purposes, as the reports contain the information necessary for consideration of the applicable criteria. VA's duty to assist is met. The Board finds that there has been compliance with the directives of the February 2012 Joint Motion and the October 2012 Board remand. In this regard, the Board notes that the RO requested that the Veteran identify pertinent treatment providers in an October 2012 letter; he identified both private and VA treatment providers, and their records have now been obtained and associated with the claims-file (including in Virtual VA). Additionally, in accordance with the directives of the Joint Motion, the Veteran was afforded a new VA psychiatric examination in the hope that progress in his recovery from a brain injury may have enabled his productive participation in such an examination (after the Veteran was essentially unable to participate in the June 2010 VA examination); as discussed below, the April 2013 VA examination report documents that the Veteran remains essentially unable to adequately communicate to participate productively in an evaluation. The Board has given careful consideration to the concern expressed in the February 2012 Joint Motion. The February 2012 Joint Motion noted "evidence that a new examination would likely be more fruitful than the June 2010 examination" due to indications of improvement in the Veteran's ability to participate. The Veteran remained unable to meaningfully participate in the April 2013 VA examination, and there has been no indication of record indicating a new material change in the prospects for a more productive result were another VA examination arranged. There is no indication that additional fruitful development is possible at this time, or that another new VA examination would yield productive results in light of the Veteran's difficulties following his head injury with damage to his speech center. Accordingly, the Board will address the merits of the claim. Legal Criteria, Factual Background, and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. With the initial rating assigned following a grant of service connection, separate (staged) ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 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 that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. PTSD is rated under the General Rating Formula for Mental Disorders. A 30 percent evaluation is warranted when the evidence demonstrates 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, and mild memory loss (such as forgetting names, directions, recent events. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9411. The Veteran has been assigned various Global Assessment of Functioning (GAF) scores. Scores ranging from 51 to 60 reflect more 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). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Lesser scores reflect increasingly severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes]. The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. On August 2005 VA treatment, the Veteran reported being laid off from work the previous week. He reported nightmares, flashbacks, and intrusive thoughts. He reported that there were aspects of his trauma that he did not recall. He reported that he avoided talking and thinking about Vietnam and felt emotionally detached from others. He reported exaggerated startle reflex, irritability, hypervigilance, and sleep disturbance. He also reported periodic symptoms of bipolar disorder including inflated self esteem, increased energy, rapid speech, racing thoughts, irritability, depression, decreased sleep, low energy, and loss of interest. He reported doing very well since being on Lithium and Lexapro. He denied all mood symptoms. He reported a history of heavy drinking and attendance at Alcoholics Anonymous. He was married for 36 years and his wife was supportive. On mental status examination, he was pleasant and cooperative with good contact and soft speech with a normal rate. Mood was "good," and affect was broad and reactive. He denied suicidal ideation, homicidal ideation, or audio/visual hallucinations. Thought processes were goal directed. Insight and judgment were good. The diagnoses included PTSD and bipolar disorder, and a GAF score of 70 was assigned. On September 2005 VA treatment, the Veteran reported problems with focus, concentration, and motivation. He reported some irritability and apathy. He reported being a little depressed and sleeping only 4 hours per night with 2 hour naps during the day. On October 2005 VA treatment, the Veteran reported being more motivated with better concentration and focus and no racing thoughts. He was assessed as being stable on current medications, including Citalopram and Lithium. On May 2006 VA treatment, the Veteran reported being depressed thinking about the events of the past. He reported that in January, he ran into a Vietnam veteran, drank alcohol, passed out, and woke up in jail charged with a DUI. He reported that normally he did not drink more than a couple of beers at a time. He reported difficulty completing the paperwork to apply for VA benefits. He reported nightmares and interrupted sleep, as well as mood swings "mostly on the low end." His prescription for Lithium was increased for mood symptoms. On May 2006 VA psychiatric examination, the Veteran reported symptoms of bipolar disorder including periods of depression and periods of elation. The depression is accompanied by thoughts of suicide and feeling down and uncomfortable, while the elation produces euphoria, energy, and racing thoughts; he took medication for a more even emotional reaction. He reported PTSD symptoms including exaggerated startle and emotional discomfort from loud noises, intrusive thoughts about his combat experience, and being reminded of his experiences in Vietnam by certain conversations. He reported that he was last employed July 29, 2005 as a civilian contractor, and before his termination was irritable, got into arguments, and walked out of meetings in protest. He was married over 30 years and had regular contact with his wife and two grown children, stating that they got along "pretty well." He reported being jailed for a DWI in January 2006, which would go to court shortly. The frequency of his PTSD symptoms increased only if he was around loud noises, if people came up behind him, or if conversation reminded him about Vietnam or his experiences; he did not have symptoms every day, but only with reminders. On mental status examination, the Veteran did not appear tense or restless. His mood was euthymic and affect was broad and flexible. Thought processes were not overabundant or "underabundant." He reported intrusive memories about his Vietnam experience. Current medications include Venlafaxine for depression and Lithium for mood disorder. His cognitive functions were intact on testing, with no memory deficit, and intact judgment and insight. The diagnoses included bipolar disorder, alcohol abuse, nicotine dependence, and PTSD manifested by disturbance, loud noises, people behind him, or clues that reminded him of his Vietnam combat and caused obsessive thoughts about his combat experiences. A GAF score of 60 was assigned, reflecting mild to moderate symptoms. Based upon the results of this examination, the May 2006 rating decision assigned an initial rating of 10 percent for PTSD. On August 2006 VA treatment, the Veteran reported being depressed for the previous 2 months, including crying "all the time," and being unable to concentrate or get things done. He reported more frequent nightmares and occasional thoughts of harming himself, but without a plan. On September 2006 VA treatment, the Veteran's mood and motivation had improved and he was sleeping more. On November 2006 VA treatment, the Veteran reported recent episodes of confusion, which he attributed to the combination of Lithium and Venlafaxine. He was learning tools to handle some of his anger and depression issues. He denied any thoughts of harming himself. Venlafaxine was to be reduced and discontinued. On January 2007 VA treatment, the Veteran reported having "sat in the garage for a couple of weeks" with suicidal thoughts. He reported that the thoughts had turned from suicidal to homicidal, with nobody in mind. He reported anger issues, rage, and outbursts, from which he was sometimes able to walk away. He felt better on a lower dosage of Lithium. On mental status examination, his mood was depressed with congruent affect. Speech was soft with regular rate and rhythm. Thought process was logical and goal directed, and judgment and insight were "ok." He denied any suicidal or homicidal ideation or auditory or visual hallucinations. The assessments included bipolar disorder, most recent episode depression, PTSD, and rule-out intermittent explosive disorder. An antidepressant was added to his medications. On February 2007 VA neuropsychology consult, the Veteran's cognitive performance was average or above average. The data were consistent with a Cluster C disorder on Axis II, a history of substance abuse, and symptoms of a thought disorder or psychotic mentation. The testing results indicated that the Veteran appeared to be labile, to be potentially dangerous to others due to rage outbursts, to have a borderline organization underlying his functioning, and to qualify for anti-social personality disorder diagnosis or strong anti-social features in combination with Cluster C personality disorder. His 37 year marriage suggested that he was able to form bonding links with some capacity for closeness and some healthy personality functioning. No cognitive deficits were found. On February 2007 private treatment, Dr. R.S. noted that the Veteran had bipolar disorder diagnosed in July 2004. He reported he did well until he lost his job and was unable to continue treatment. His most recent medication regimen consisted of lithium and Zoloft, though he had not taken any medication in about three weeks. He reported a recent episode when he became acutely psychotic and was arrested on a weapons charge, which troubled him quite a bit. On examination, mood and affect appeared appropriate, and he was alert and oriented and in no acute distress. Testing revealed severe anxiety and severe depression. The assessment was bipolar disorder; Seroquel was prescribed. Based upon these reports, a February 2007 rating decision increased the initial rating for PTSD to 30 percent, again effective November 15, 2005. On March 2007 VA treatment, the Veteran reported that he had improved since he was put on Quetiapine. He had not gotten angry in weeks, though he still avoided large crowds of people. He was no longer having memory problems like before. His mood was good with congruent affect. Thought process was logical and goal directed. Judgment and insight were ok. He was noted to be improving. On May 2007 VA treatment, the Veteran reported that his "highs and lows" were moderate. He reported that he had been depressed for 3 to 4 days the previous week. He reported constantly thinking about Vietnam and being unable to recall some events. He reported he had no paranoia or strange dreams, and that he was sleeping 7 to 8 hours per night since starting Quetiapine. On June 2007 VA treatment, the Veteran reported improved sleep, less anxiety, and improved mood and energy on the current medication regimen. He reported nightmares, startle response, intrusive thoughts, and fear of watching television related to the ongoing Iraq war, because news about the war brought back memories related to his Vietnam experience. He denied auditory or visual hallucinations, paranoia, delusional thinking, and suicidal or homicidal ideation, and appeared to be no danger to himself or others. On mental status examination, he easily responded to verbal stimuli with good eye contact. Speech was well modulated with normal tone and volume, thought content was clear and organized, affect was restricted, and mood was stated as 6 out of 10. He was goal oriented for the future with good insight and judgment. On July 19, 2007 VA evaluation, the Veteran's reality testing appeared to be good. He was occasionally emotionally tearful and stressed. He reported no suicidal or homicidal thoughts and no alcohol or drug use. He reported that he had held 10 jobs since leaving military service and "had to stop working" 2 years earlier. He noted difficulty with relationships at work due to rage/anger outbursts. He reported that his current medications were helpful in reducing Vietnam nightmares and helped him sleep, though he still had crying spells, intrusive war memories, trouble remembering important parts of his traumatic experiences, irritability, and hypervigilance. He reported feeling jumpy and getting upset when something would remind him of Vietnam or the current wars. He reported brief flashbacks, physical reactions when reminded of his trauma, trouble concentrating, and a feeling of a foreshortened future. He reported continuing to enjoy working on his motorcycle, in the yard, and on puzzles, and that most of his close friends were Vietnam veterans as well. The assessments included chronic PTSD, bipolar disorder, alcohol use in recovery for 11 months, and impulse control disorder. A GAF score of 45 was assigned. On October 2007 VA psychiatric examination, the Veteran reported being unemployed since July 2005. He stated that he was a civilian contractor with the military; he reported being irritable and walking out of meetings and having "blowups," and he therefore "left the job." He reported that he tried working for 3 weeks in June 2006 but was laid off after being hired because he could not get security clearance due to his mental health problems, and he had not tried working since that time. He reported group therapy treatment; medication management including Quetiapine, which helped with mood and sleep. He reported feeling depressed when people would discuss Vietnam, and the depression lasted for a couple of days. He reported thinking about suicide at times. He reported significant anger problems that had been worse but were improved at the time of examination. He reported uncontrollable rage associated with heavy drinking in the past. He reported getting one or two hours of sleep at a time and waking up throughout the night; taking Seroquel had improved his sleep to the point of getting about seven hours per night. He denied any significant nightmares since beginning to take Seroquel, though he reported earlier nightmares of explosions and people running. He did not think about Vietnam as much as before unless it was specifically brought up in conversation. He would become agitated for a couple of days after group therapy. He had suppressed his issues until 1986, when he got a job that seemed to trigger the memories; his symptoms improved until the Iraq war began, when they worsened again. He had a history of heavy drinking, but had stopped entirely in 2006; he denied any current drinking. He received a DWI and was jailed in 2006. He reported having a "pretty good" relationship with his wife and receiving a lot of support from close friends and other Vietnam veterans. He reported a number of leisure activities. On mental status examination, the Veteran spoke softly and was difficult to understand. He began to cry when discussing Vietnam issues, though he stifled his response extensively and became very tense. He showed poor social skills and rapport was difficult to establish. He was estimated to have superior range intelligence based on conversation and his history. Thought process was logical, coherent, and relevant. Affect was constricted and very blunted, and tearful once or twice. Reasoning and judgment were good, and he was well oriented to time, place, person, and situation. Fund of general information and verbal comprehension were above average to superior. Short term memory was reported as good, though the Veteran reported gaps in his long term memory specifically related to trauma. He reported trouble concentrating when thinking about his war experiences. He reported multiple head injuries as a child, though no significant cognitive deficits were found on neuropsychological evaluation. He reported significant manic symptoms that began in service, and a most recent episode of being depressed with less interest in doing things, fatigue, and sometimes feeling suicidal. He denied having psychotic symptoms, though his medication apparently induced some psychosis. The examiner opined that the Veteran showed signs of grandiosity and likely paranoia/schizotypal tendencies based on previous testing and history, which the examiner opined may be associated with his bipolar disorder. The examiner diagnosed bipolar I disorder, most recent episode depressed; PTSD; alcohol dependence in current remission by self-report; and borderline personality disorder with additional antisocial schizoid and passive-aggressive traits on Axis II. A GAF score of 55 was assigned. The examiner opined that there was only moderate impact of mental health symptoms on social functioning. The Veteran indicated that he was having more conflicts on the job which led him to stop working. He reported a history of explosive behavior, though this appeared to relate mainly to his drinking; he reported maintaining sobriety and improved control of his anger. The examiner opined that the Veteran's bipolar and PTSD symptoms impacted on his ability to work, though they improved with medication. The examiner opined that the Veteran had shown an ability to find and maintain employment when he is more stable, even doing quite well in terms of job performance. The examiner opined that most of the Veteran's reported problems on the job related to interpersonal problems, which were largely accounted for by the personality disorder. The examiner opined that the Veteran's PTSD had a "highly dissociative quality" to it, and at least some of his symptomatology related to his significant trauma in childhood, which made him more at risk for developing PTSD related to his military trauma later in life. The examiner opined that the Veteran's PTSD only contributed approximately a third to his overall occupational and social dysfunction, considering his other mental health issues. The examiner opined that the bipolar disorder appeared to have emerged in service. The total GAF score associated reflected some social and occupational dysfunction to a moderate degree, with moderate symptoms on examination, though his symptom severity had fluctuated along with his manic and depressive episodes over the years. The examiner estimated that 75 percent of the GAF score could be accounted for by the bipolar disorder and PTSD, with the other 25 percent accounted for by the personality disorder. The examiner opined that the PTSD did not cause the Veteran to be 100 percent unemployable in his normal occupational environment. On July 2008 VA treatment, the Veteran reported he could not recall some events in Vietnam. He reported he did not have paranoia or strange dreams. He had mild nausea with Celexa. He denied depression, mania, psychosis, and suicidal or homicidal ideation. His mood was euthymic with restricted affect, and easily engaged with soft speech. Thought process was logical. The assessments included mild bipolar disorder, PTSD, and alcohol abuse in sustained full remission. Celexa was to be reduced and discontinued while Quetiapine was continued at the same dosage. In a December 2008 statement, the Veteran's spouse described her history with the Veteran from their first meeting approximately 2 months after his return from Vietnam through the present. She described his PTSD symptoms and his course of treatment, including a series of medications that caused side effects including drowsiness, paranoia, and problems with memory and attention span. VA records show the Veteran was hospitalized for PTSD treatment from January 7, 2009 through February 27, 2009. An August 2010 rating decision granted a temporary total (hospitalization) rating from January 7, 2009 through March 1, and the rating for this time period is not before the Board. On February 27, 2009 discharge summary, the diagnoses included PTSD and episodic alcohol dependence in remission. On mental status examination, the Veteran was calm and cooperative, and his speech was fluent, normal, and coherent. His mood was ok, and affect was euthymic. Thoughts were logical and goal directed. There was no evidence of suicidal ideation, homicidal ideation, or psychosis. Insight and judgment were good; he was assessed to be cognitively grossly intact. On March 2009 VA treatment, the Veteran reported attending a 7 week PTSD program that "helped him deal with certain issues he never dealt with." He reported doing well overall but having stress from being unemployed, trying to sell his home, and demands from his wife. He reported that Seroquel was helping with sleep, voices, racing thoughts, and mood stabilization; he denied any depression, mania, psychosis, or suicidal or homicidal ideation. The assessments included PTSD, bipolar disorder (noted as fairly stable), and alcohol abuse (in sustained full remission). On June 2010 VA psychiatric examination, pursuant to the Board's remand, the examiner noted that the Veteran's psychotropic medications included Quetiapine for mood and Alprazolam for anxiety. The examiner noted that the Veteran was first treated in August 2005 for PTSD and bipolar disorder, began PTSD group therapy in July 2007, was admitted in January/February 2009, and briefly continued with PTSD group therapy for a few sessions after hospitalization. The examiner noted that the Veteran was in a motorcycle accident in April 2009 shortly after his discharge from PTSD hospitalization. The Veteran's wife reported that he had been in a coma for one month and then in two induced comas for 3 weeks and 2 weeks, respectively, to treat MRSA and pneumonia. She reported that he was learning to walk and speak again, and would not talk unless he wanted to. On examination, he was "stuporous," nonresponsive, and seated in a wheelchair with an oxygen tank. The examiner attempted to interview the Veteran and his wife, who reported that the Veteran did not seem particularly depressed since he was taking Quetiapine/ Seroquel, though he was not taking the Alprazolam. The Veteran was very slightly responsive to questions with nods and motions, according to his wife. She reported that he was able to match pictures with words and return upside-down items to being right-side-up. He did not speak or verbally respond in the preliminary nursing screening. He was nonresponsive to questioning and was not alert. His wife explained that he would often "shut down" and refuse to talk, though he was better in the afternoons. The examiner stated that no further exam to assess PTSD or other mental health disorder could be conducted; though the examiner opined that the Veteran appeared to be severely impaired from dementia from head trauma as reported by his wife. The diagnosis was dementia due to head trauma with behavioral disturbance. In an addendum opinion issued later in June 2010, following review of the claims file, the VA examiner noted again that due to the Veteran's stuporous, unresponsive presentation in contrast to the other clinical presentations and evaluations found in the medical record, a psychological evaluation for PTSD could not be conducted. The examiner noted that, according to the history provided by the wife and the Veteran's presentation, severe cognitive impairment appeared to be the more salient issue, though the claims file records did indicate a history of PTSD, bipolar disorder, alcohol dependence, and personality disorder. A November 2010 rating decision increased the rating for PTSD to 50 effective July 19, 2007, the date on which (according to the RO) the evidence first showed that the Veteran's symptoms merited a higher evaluation. The 50 percent rating was to be resumed following the period of temporary total evaluation from January 7, 2009 to March 1, 2009. The November 2010 rating decision also granted a TDIU rating, also effective July 19, 2007. The Veteran has identified/submitted VA treatment records through June 2009. Such records, in addition to those cited above, reflect symptoms similar to those noted on May 2006, October 2007, and June 2010 VA examinations. Following the February 2012 Joint Motion and the October 2012 Board remand, a new VA examination was attempted in April 2013. The report of the examination includes the examiner's explanation that "[the Veteran's] speech center was damaged during the [April 2009 motorcycle] accident and his speech was improving." The examiner reported: "During this evaluation, the examiner was unable to communicate with the veteran." The examiner explained: "He could make verbal sounds and gesture with his hands, but this examiner was unable to ask questions related to changes related to his PTSD that have occurred since 2009." The Veteran "could not express himself." Finally, "[w]hen the Veteran grew tired of being in the room ... he began pushing himself toward the door. He left the office with his daughter." The examiner noted that the Veteran's wife "noted the Veteran spends his day 'smoking, sleeping, going for car rides, cutting up things and stuffing in soda cans, read a very little, watch some TV.'" The record reflects that the Veteran has been assigned psychiatric diagnoses other than PTSD (most notably bipolar disorder) which are not service connected. While symptoms/impairment due to disability that is not service connected generally may not be considered in rating a psychiatric disability, governing caselaw provides that where it is not possible to distinguish the effects of a nonservice-connected disability from those of the service-connected disability being rated, the reasonable doubt doctrine dictates that all symptoms be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App, 181 (1998). In the instant case, the examiners have for the most part not distinguished symptoms due to the Veteran's PTSD from those due to other co-existing and nonservice-connected psychiatric diagnoses [although some interpersonal difficulties were attributed to a personality disorder]. For the limited purposes of this appeal only, the Board will consider all psychiatric symptoms shown as due to the service-connected PTSD. Notably, in assigning the ratings on appeal the RO did not exclude any symptoms from consideration as due to nonservice-connected disability. Addressing the staged ratings assigned for the Veteran's PTSD in turn, the Board notes that the reports of the VA examinations and the VA treatment records, overall, provide evidence against the Veteran's claim as they do not show that, prior to July 19, 2007, symptoms of his PTSD produced occupational and social impairment with reduced reliability and productivity, so as to meet the criteria for a 50 percent rating. He did not, for example, display 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; or difficulty in establishing and maintaining effective work and social relationships. While he was not employed, it was due to a reduction in force (as reported by his employer). The demonstrated impact of the PTSD on his level of functioning, as reflected by his relationships with family and friends, is inconsistent with a disability picture of reduced reliability and productivity. Furthermore, the GAF scores (and the reported symptoms they represent) are not inconsistent with the schedular criteria (and do not provide a separate basis for rating the PTSD). Consequently, prior to July 19, 2007 a schedular rating in excess of 30 percent was not warranted. From July 19, 2007, the VA examinations and treatment records, overall, do not show that symptoms of the Veteran's PTSD have at any time produced deficiencies in most areas, so as to meet the criteria for a 70 percent rating. He has not, for example, displayed suicidal ideation (any reported suicide attempts were in the past, prior to the appeal period), obsessional rituals which interfere with routine activities (no such rituals were reported), intermittently illogical, obscure, or irrelevant speech, near-continuous panic or depression, impaired impulse control, spatial disorientation, difficulty in adapting to stressful circumstances, or an inability to establish and maintain effective relationships. While he indicated at times that he had difficulties with memory and/or concentration, examination revealed he had no slowness of thought processes or confusion; indeed, he later attributed such symptoms to improper medication levels. While the observations by the October 2007 VA examiner reflect the Veteran has had social impairment due to PTSD symptoms, such impairment is clearly encompassed by the criteria for a 50 percent rating. More recent apparently more severe cognitive impairment (noted in June 2010 and April 2013) and impairment in the Veteran's ability to communicate have been attributed to head trauma sustained in an incurrent motorcycle accident. Consequently, a schedular rating in excess of 50 percent is not warranted at any time. The Board notes the GAF score of 45 assigned on July 19, 2007 VA treatment, which would appear to suggest a higher level of psychiatric impairment than is recognized by a 50 percent rating. However, that score is unexplained, is inconsistent with contemporaneous reports of actual symptoms, and in light of the overall evidence may not reasonably be found dispositive. GAF scores of 41 to 50 reflect serious symptoms such as suicidal ideation, severe obsessional rituals, or frequent shoplifting; or any serious impairment in social, occupational or school functioning such as having no friends or being unable to keep a job. No such (or similar) symptoms are shown in this case: at the time the GAF score of 45 was assigned, the Veteran reported no suicidal thoughts, had a lot of support from close friends, and had a good relationship with his wife. The Board also notes that, three months later on October 2007 VA examination, a GAF score of 55 was assigned, reflecting the moderate symptoms shown throughout the remainder of the appeal period. The Board notes the lay statements submitted by the Veteran and his wife in support of this claim. Those statements detail the types of problems that result from the Veteran's PTSD symptoms (difficulty concentrating, nightmares, irritability, etc.). The levels of functional impairment described by the Veteran are consistent with (and do not exceed) the criteria for a 30 percent rating prior to July 19, 2007, and a 50 percent rating from July 19, 2007 to the present. The Board also notes the recent lay statement submitted by the Veteran's daughter in January 2013 describing his behavior during her childhood in the "1970s". It does not meaningfully expand or enhance the information of record regarding the period on appeal (beginning with the grant of service connection for PTSD in November 2005)., and does not support that a higher rating is warranted. In summary, it is not shown that prior to July 19, 2007 the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity, or that since that date it has been manifested by symptoms productive of deficiencies in most areas (or approximating such level of severity). Consequently, increases in the "staged" schedular ratings assigned are not warranted. 38 C.F.R. § 4.7. The Board has considered whether this claim warrants referral for consideration of an extraschedular rating. Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. Comparing the manifestations of the Veteran's PTSD to the criteria in the rating schedule, the Board finds that the PTSD symptoms and associated impairment shown are wholly encompassed by criteria for the schedular ratings assigned. Consequently those criteria are not inadequate. [The additional disability involving the Veteran's ability to communicate shown following the intercurrent postservice motorcycle accident is not service-connected, and may not be considered in rating the PTSD.] The Veteran's PTSD hospitalization within the evaluation period has already been recognized by a corresponding period of temporary total rating. Consequently, the Board finds that referral of this case for consideration of an extraschedular rating pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Finally, it is noteworthy that an unappealed November 2010 rating decision awarded the Veteran a TDIU rating effective from July 19, 2007, and that the matter of entitlement to such rating is moot. ORDER The appeal seeking increases in the staged ratings (of 30 percent prior to July 19, 2007 and 50 percent from that date) assigned for the Veteran's PTSD is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs