Citation Nr: 0813470 Decision Date: 04/24/08 Archive Date: 05/01/08 DOCKET NO. 04-38 741 ) DATE ) ) On appeal from the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma THE ISSUE Entitlement to an initial rating in excess of 30% for a post- traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Thomas A. Pluta, Counsel INTRODUCTION The veteran had active service from October 1965 to October 1967. This appeal to the Board of Veterans Appeals (Board) arises from a September 2003 rating action that granted service connection for PTSD and assigned an initial 30% rating therefor from August 2002. Because the appeal involves a request for a higher rating assigned following the initial grant of service connection, the Board has characterized it in light of the distinction noted by the U.S. Court of Appeals for Veterans Claims (Court) in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service- connected disability). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. The veteran's PTSD is manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to such symptoms as a depressed mood, anxiety, panic attacks, sleep impairment, and mild memory loss; he generally functions satisfactorily, with normal routine behavior, self-care, and conversation. CONCLUSION OF LAW The criteria for an initial rating in excess of 30% for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist In November 2000, the Veterans Claims Assistance Act of 2000 (VCAA) was signed into law. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002). To implement the provisions of the law, the VA promulgated regulations at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of the VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify him what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of the VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Considering the record in light of the duties imposed by the VCAA and its implementing regulations, the Board finds that all notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. In Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), the Court held that, for an increased-compensation claim, 38 U.S.C.A. § 5103(a) requires, at a minimum, that the VA notify a claimant that, to substantiate a claim, he must provide, or ask the VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability, and the effect that worsening has on his employment and daily life. Further, if the Diagnostic Code (DC) under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by him demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on his employment and daily life (such as a specific measurement or test result), the VA must provide him with at least general notice of that requirement. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant DCs, which typically provide for a range in severity of a particular disability from 0% to as much as 100% (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the VA to obtain) that are relevant to establishing entitlement to increased compensation - e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating thereto. In this case, a November 2002 pre-rating and December 2003, March 2004, and May 2006 post-rating RO letters collectively informed the veteran and his representative of the VA's responsibilities to notify and assist him in his claim, and to advise the RO as to whether there was medical evidence (such as statements from doctors and examinations containing clinical findings) showing treatment for his psychiatric disability, and lay evidence (such as statements from individuals describing his symptoms from their knowledge and personal observation) demonstrating a worsening of the disability. Those letters also provided notice of what was needed to establish entitlement to a higher rating (evidence showing that the disability had worsened). An August 2007 post-rating RO letter informed the veteran that, if an increase in disability was found, a disability rating would be determined by applying relevant DCs which provided for a range in severity from 0% to 100%, based on the nature and symptoms of the condition, their severity and duration, and their impact upon employment. That letter also provided examples of the types of medical and lay evidence that the veteran may submit (or ask the VA to obtain) that are relevant to establishing entitlement to increased compensation - e.g., competent lay statements describing symptoms, medical records, employer statements, and other evidence showing an increase in the disability. Thereafter, the veteran and his representative were afforded opportunities to respond. The Board finds that the veteran has thus received sufficient notice of the information and evidence needed to support his claim, and has been provided ample opportunity to submit such information and evidence. The 2002, 2003, and 2004 RO letters also notified the veteran that the VA would make reasonable efforts to help him get evidence necessary to support his claim, such as medical records (including private medical records), if he gave it enough information, and, if needed, authorization, to obtain them. The 2003, 2004, and 2006 RO letters further specified what records the VA had received; what records the VA was responsible for obtaining, to include Federal records; and the type of records that the VA would make reasonable efforts to get, and variously requested the veteran to furnish any medical records or evidence that he had in his possession that pertained to his claim. The Board thus finds that the 2002, 2003, 2004, and 2006 RO letters collectively satisfy the statutory and regulatory requirement that the VA notify a claimant what evidence, if any, will be obtained by him and what evidence will be retrieved by the VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Board points out that, in the decision of Pelegrini v. Principi, 17 Vet. App. 412 (2004), the Court held that proper VCAA notice should notify a veteran of: (1) the evidence that is needed to substantiate a claim; (2) the evidence, if any, to be obtained by the VA; (3) the evidence, if any, to be provided by the claimant; and (4) a request by the VA that the claimant provide any evidence in his possession that pertains to this claim. As indicated above, all 4 content of notice requirements have been met with in this appeal. Pelegrini also held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided at the time that, or immediately after, the VA Secretary receives a complete or substantially complete application for VA-administered benefits. In that case, the Court determined that the VA had failed to demonstrate that a lack of such pre-adjudication notice was not prejudicial to the claimant. In the matters now before the Board, documents meeting the VCAA's notice requirements were furnished to the veteran both prior and subsequent to the initial September 2003 rating action on appeal. However, the Board finds that, in this appeal, any delay in issuing the full 38 U.S.C.A. § 5103(a) notice was not prejudicial to the veteran because it did not affect the essential fairness of the adjudication, in that his claim was fully developed and readjudicated after notice was provided. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir.2006). As indicated above, the veteran has been notified of what was needed to substantiate his claim, and afforded numerous opportunities to present information and/or evidence in support thereof. As a result of RO development, comprehensive documentation, identified below, has been associated with the claims folder and considered in connection with the veteran's appeal. After the 2002, 2003, 2004, and 2006 RO notice letters, the RO gave the veteran further opportunities to furnish information and/or evidence pertinent to the claim before it readjudicated it on the basis of all the evidence of record in September 2004 (as reflected in the Statement of the Case) (SOC) and April and May 2007 (as reflected in the Supplemental SOCs). In March 2006, during the pendency of this appeal, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that, in rating cases, a claimant must be informed of the rating formula for all possible schedular ratings for an applicable rating code. In this case, the Board finds that this was accomplished in the September 2004 SOC, and that this suffices for Dingess/Hartman. The Court also held that the VA must provide information regarding the effective date that may be assigned; such notice was provided by letter of August 2007. Additionally, the Board finds that all necessary development on the claim currently under consideration has been accomplished. The RO, on its own initiative, has made reasonable and appropriate efforts to assist the appellant in obtaining all evidence necessary to substantiate his claim, to include obtaining available post-service VA and other medical records through 2007. In January 2003, January 2004, February 2006, and February 2007, the veteran was afforded comprehensive VA psychiatric examinations in connection with his claim, and numerous medical records document regular follow-up psychological and psychiatric evaluations of his PTSD through 2007; all of these reports are of record and have been considered in adjudicating this claim. A copy of the October 2002 Social Security Administration (SSA) decision granting the veteran disability benefits, together with extensive medical records underlying that determination, have been associated with the claims folder. Significantly, neither the veteran nor his representative has identified, and the record does not otherwise indicate, any existing, pertinent evidence, in addition to that noted above, that has not been obtained. In January and May 2006 and May and June 2007 statements, the veteran stated that he had no additional information or evidence to submit in connection with his claim. In August 2007, the veteran's representative submitted additional evidence to the Board, together with a waiver of the veteran's right under 38 C.F.R. § 20.1304(c) (2007) to have the RO initially review it. The record also presents no basis for further development to create any additional evidence to be considered in connection with the matter currently under consideration. Under these circumstances, the Board finds that the veteran is not prejudiced by appellate consideration of the claim on appeal at this juncture, without directing or accomplishing any additional notification and/or development action. II. 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 of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of 2 ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson, 12 Vet. App. at 126. The veteran's PTSD has been initially rated as 30% disabling under the provisions of 38 C.F.R. § 4.130, DC 9411. Under that DC, a 30% rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation), 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% rating requires 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; and difficulty in establishing and maintaining effective work and social relationships. A 70% rating requires occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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. A 100% rating requires total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting oneself or others; intermittent ability 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 or one's own occupation or name. Considering the pertinent evidence in light of the criteria of DC 9411, the Board finds that the veteran's PTSD has not been more than 30% disabling at any time since the initial grant of service connection. The medical evidence of record documents that the service-connected PTSD is manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to such symptoms as a depressed mood, anxiety, panic attacks (weekly or less often), sleep impairment, and mild memory loss, but the veteran generally functions satisfactorily, with normal routine behavior, self-care, and conversation. In arriving at this determination, the Board notes that, by rating action of January 2006, the RO granted a temporary total rating of 100% (T/TR) under the provisions of 38 C.F.R. § 4.29 for hospitalization for PTSD for a period in excess of 21 days from 20 September through October 2005; a schedular 30% rating was restored from November 2005. Thus, the period that the T/TR was in effect has been excluded from consideration for increase for PTSD under the schedular rating criteria. On August 2002 psychiatric examination by J. S., M.D., the veteran complained of daily recurrent memories of his Vietnam combat experiences, increased panic attacks, and startle reactions. On examination, he cried easily and became very anxious. The examiner noted severe startle reactions, increasing social isolation, decreased concentration, and ability to work only occasionally as a janitor because of unease around people. The veteran was not suicidal. The diagnoses were chronic, severe, delayed-onset PTSD manifested by startle reactions, recurrent dreams, intrusive thoughts, social isolation, irritability, and increasing difficulty functioning in any work situation; diabetes; and severe osteoarthritis of the spine with natural fusion. A Global Assessment of Functioning (GAF) score of 40 was assigned on the basis of all those disabilities, and the doctor stated that the veteran's condition would continue to deteriorate, and that he was unable to work. On January 2003 VA psychiatric examination, the veteran was noted to be currently employed as an evangelist, traveling extensively and working and praying with people with drug and alcohol problems. He frequently talked to many different people on his cellular telephone, attended church services twice a week, and also went to revivals and singing groups. On mental status examination, there was no impairment of thought processes or ability to communicate and no delusions, severe depression, hallucinations, panic attacks, abnormal or obsessive or impulsive or ritualistic behavior, or recent suicidal or homicidal ideation. Personal hygiene was good, and grooming and dress normal. He was oriented in 3 spheres, and memory was good. Speech was spontaneous, coherent, relevant, and adequately organized, without blocking, slowing, or circumstantiality, and he abstracted proverbs well. The veteran appeared somewhat anxious, and complained of sleep problems, but was able to carry on his daily life adequately. He was able to establish and maintain social and work relationships, and follow simple to moderately complex instructions. The diagnosis was PTSD, and a GAF score of 90 was assigned. On January 2004 VA psychiatric examination, the veteran appeared very anxious, with his symptoms much controlled on medication. He complained of an easy startle reaction, anxiety, panic attacks, depression, lack of energy, difficulty sleeping, and loneliness. His only hobby was the Internet. He had had some educational accomplishment, having become an ordained minister in his church. Marital, family, work, and social relationships were reportedly not good. On mental status examination, the veteran was oriented in 3 spheres. He described some paranoid and magical thinking and suicidal thoughts, but denied homicidal and current suicidal thoughts, and stated he would not act on them. Personal hygiene was moderate. The examiner noted some memory impairment, and that the veteran's physical health and quality of life were not good, and that his physical condition was deteriorating. The diagnoses were PTSD, chronic dysthymic disorder with episodes of major depression, history of alcohol dependence in remission, evidence of some mild cognitive defects, diabetes mellitus, and bilateral knee arthritis. A GAF score of 50 was assigned on the basis of all those disabilities, and the doctor stated that the veteran really had no social relationships. He was capable of managing his financial affairs. The veteran presented as tense and anxious, yet controlled, on March 2004 PCC Mental Health/Social Service outpatient evaluation. He complained of hypervigilance, flashbacks, and disturbing dreams. The assessment was PTSD by history. On August 2004 VA outpatient social work evaluation, the veteran complained of difficulty controlling his anger at times, and being always "on edge." He was an evangelical minister, and was unemployed. Describing his social support system, the veteran reported turning to other ministers for counseling. He currently lived with his 3rd wife in an apartment, having been divorced twice. He read Christian literature in his leisure time. On mental status evaluation, the veteran was oriented in 4 spheres, and casually dressed and groomed. Thought content was coherent, without suicidal or homicidal ideation. Affect was anxious, and memory good. Insight and judgment were poor. Regarding cognitive flexibility, the veteran seemed accepting of new ideas, and speech and flow of thought were normal. Behavior was cooperative. On September 2004 VA outpatient psychiatric evaluation, the veteran was treated for a panic disorder and a history of PTSD, and a GAF score of 60 was assigned. On March and April 2005 VA outpatient evaluations, orientation, judgment, and insight were within normal limits. Speech was clear and understandable. Affect was alert, and the veteran was cooperative. On April occupational therapy evaluation, the veteran complained of PTSD and anxiety. He was alert and oriented in 4 spheres, and his perceptual skills and memory were within functional limits. A social work evaluation noted that the veteran traveled and ministered to Native Americans, and stayed with friends and family. He had 2 brothers and 2 sisters, and they were a supportive family. The veteran was alert and oriented and very motivated to continue witnessing to others about his faith, in which he was a certified minister. On July 2005 VA outpatient psychiatric evaluation, the veteran was not very cooperative with questioning, and was irritable and easily angered and pressured, with flight of ideas, tangential thinking, and hypomanic and inappropriate behaviors (hugging the examiner). On examination, the veteran was dressed appropriately. There was psychomotor agitation and animation, and attitude was hostile. Affect/mood was labile, speech pressured, and thoughts tangential, with dysphoric content. The veteran was oriented in 3 spheres, and insight was average. The diagnoses included PTSD, and a GAF score of 51 was assigned. On August 2005 VA outpatient psychiatric evaluation, the veteran was still quite pressured, with depression, flight of ideas, and inability to focus on the issue at hand. He described stress at home as a result of the death of his sister from cancer. On examination, the veteran was dressed appropriately. There was psychomotor agitation/retardation, and attitude was cooperative. Affect/mood was labile, speech pressured, with loose associations. Thought content was dysphoric, with paranoid trends and delusions. The veteran was oriented in 3 spheres, and insight was poor. The veteran was felt to be no risk to harm himself or others. The diagnoses included PTSD, and a GAF score of 55 was assigned. In late August 2005, the veteran was hospitalized at a VA medical facility for detoxification. He reported sleeping 8 hours per night. Speech was rapid, with pressure and flight of ideas. There was no suicidal or homicidal ideation or evidence of psychosis at the time of hospital discharge. The diagnoses were PTSD, mood disorder, and sedative hypnotic abuse, and a GAF score of 55 was assigned. On late August 2005 outpatient mental health and social work evaluations, the veteran reported feeling well and better than he had in a long time. He was noted to be an ordained Pentecostal minister. On early September 2005 VA outpatient psychiatric evaluation, the veteran reported sleeping fairly well and easily, and a happy mood, but he was still quite hypomanic and easily irritated when questioned. On examination, the veteran was dressed appropriately. There was psychomotor agitation/retardation, and attitude was cooperative. Affect/mood was inappropriate, with pressured speech and dysphoric thought content. He was oriented in 3 spheres, and insight was good. The veteran was felt to be no risk to harm himself or others. The diagnoses included chronic PTSD, and a GAF score of 55 was assigned. In mid-September 2005, the veteran was hospitalized at a VA medical facility for medication stabilization. Prior to admission, he was alert, oriented, pleasant, and cooperative, with a somewhat manic mood and anxious affect, with pushed, perseverative speech; he denied suicidal and homicidal ideation, hallucinations, and delusions. There was no evidence of psychosis at the time of hospital discharge, and it was felt that the veteran could return to normal activity. The diagnoses were PTSD, mood disorder, and sedative hypnotic abuse, and a GAF score of 65 was assigned. From 20 September to mid-October 2005, the veteran was hospitalized at a VA medical facility. There was no suicidal or homicidal ideation or evidence of psychosis at the time of hospital discharge, and the veteran was stable; it was felt that he could return to normal activity. The diagnoses were PTSD and bipolar disorder, and a GAF score of 65 was assigned. Late October 2005 VA outpatient records indicated that the veteran's PTSD had been treated and was thought to be improved. On mid-February 2006 PCC Mental Health/Social Service outpatient evaluation, the veteran was noted to be doing evangelistic work. On mental status examination, he was pleasant and cooperative. Thoughts were goal-directed, and there were no hallucinations or suicidal or homicidal ideation. He was cognitively intact. The assessments were PTSD, and medication dependence in remission. On late February 2006 VA psychiatric examination, the veteran complained of nightmares of his Vietnam combat experiences 3 or 4 times per month, with problems getting back to sleep thereafter; frequent recurrent thoughts of the war; difficulty getting along with people and showing affection toward loved ones; easy anger over trivial matters; an increased startle response; and hypervigilance and difficulty concentrating at times. Since 1990, he had done evangelistic work, praying for people, visiting them in hospitals, counseling those with marital, drug, and alcohol problems, and preaching once or twice per month. He read Christian literature and the Bible during the day, and visited with his 2 brothers and 2 sisters. He attended church every Sunday and sometimes on Wednesdays, occasionally went to church dinners and revivals, did his own laundry, shopping, and cooking, paid his own bills, and washed dishes. He lived alone, and dined with his ex-wife approximately every other week. On mental status examination, there was no impairment of thought processes or ability to communicate and no delusions, hallucinations, panic attacks, abnormal or obsessive or impulsive or ritualistic behavior, or recent suicidal or homicidal ideation. Personal hygiene was good, and grooming and dress normal. He was oriented in 3 spheres, and memory was good. Speech was spontaneous, coherent, relevant, and adequately organized, without blocking, slowing, or circumstantiality, and he abstracted proverbs well. The veteran appeared somewhat anxious, and complained of sleep problems, but was able to carry on his daily life fairly adequately. He was able to establish and maintain social relationships with family and church friends, and to follow simple to moderately complex instructions, but he was not able to work at a regular job. He was not in danger of harming himself or others. The diagnosis was PTSD, and a GAF score of 65 was assigned. The examiner commented that the disturbance caused distress or impairment in social and occupational functioning due to difficulty concentrating and being distant and estranged from people. On April 2006 VA outpatient psychiatric evaluation, the veteran was noted to be doing fairly well on prescribed medication. On examination, he was alert and oriented in 4 spheres, and appearance, speech, and kinetics were normal, with good eye contact, mood, insight, and judgment. Affect was appropriate and not restricted or labile, and there were no suicidal or homicidal ideations, hallucinations, or delusions. Thought process was logical and goal-directed, and memory was intact. The assessments were history of PTSD, and panic attacks versus panic disorder. On September 2006 VA outpatient psychiatric evaluation, the veteran was noted to be under a lot a stress at home as a result of 2 teenage grandchildren living with him and his wife. He obtained some relief from prescribed medication. On examination, the veteran was alert and oriented in 4 spheres, and appearance, speech, and kinetics were normal, with good eye contact, mood, insight, and judgment. Affect was appropriate and not restricted or labile, and there were no suicidal or homicidal ideations, hallucinations, or delusions. Thought process was logical and goal-directed, and memory was intact. The assessment was PTSD with panic attacks. In a March 2007 statement, D. O., M.D., the veteran's primary case physician, stated that he had observed no improvement in the veteran's mental health over many years. From June to July 2007, the veteran was hospitalized at a VA medical facility with complaints of short-temperedness, anger, mood swings, combat dreams, and a startle reaction. He stated that he slept 8 hours per night. The examiner noted no rapid speech or flight of ideas. During his hospital course, the veteran attended a PTSD program and did well, with no behavioral problems and a stable mood. At the time of hospital discharge, there were no suicidal or homicidal ideation and no evidence of psychosis, and the veteran was stable, with a good prognosis. The diagnoses were PTSD and sedative/hypnotic/anxiolytic abuse, and a GAF score of 65 was assigned. Considering the evidence in light of the criteria noted above, the Board finds that the veteran's PTSD symptoms from 2002 to 2007 have been indicative of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to such symptoms as a depressed mood, anxiety, sleep impairment, and mild memory loss, but that he generally functions satisfactorily, with normal routine behavior, self- care, and conversation, thus meeting the criteria for no more than an initial 30% rating. The Board also notes that there has been no suspiciousness. Moreover, the Board finds that the symptoms associated with the veteran's PTSD simply do not meet the criteria for at least the next higher 50% rating, that is, occupational and social impairment with reduced reliability and productivity due to such symptoms as: a flattened affect; 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); disturbances of motivation; and chronic impaired judgment and abstract thinking. Although the veteran has some difficulty in establishing and maintaining effective work and social relationships due to difficulty concentrating and being distant and estranged from people, the Board notes that he has been effectively doing evangelistic work as an ordained church minister for many years, traveling nationwide, praying for people, visiting them in hospitals, counseling those with marital, drug, and alcohol problems, and preaching once or twice per month. He also read Christian literature and the Bible during the day, visited with his 2 brothers and 2 sisters, and was able to establish and maintain social relationships with family and church friends. He attended church every Sunday and sometimes on Wednesdays, occasionally went to church dinners and revivals, did his own laundry, shopping, and cooking, paid his own bills, washed dishes, and dined with his ex-wife approximately every other week. The Board also notes that the veteran had been assigned GAF scores ranging from 40 to 90, as reflected in VA clinical records and examination reports from 2002 to 2007. According to the 4th Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), GAF scores between 31 and 40 are indicative of 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. a depressed man avoids friends, neglects family, and is unable to work). GAF scores between 41 and 50 are indicative of 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, inability to keep a job). GAF scores between 51 and 60 are indicative of moderate symptoms (e.g., a flat affect and circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., having few friends, having conflicts with peers or co- workers). GAF scores between 61 and 70 are indicative of some mild symptoms (e.g., a depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but indicate that the subject generally functions well, and has some meaningful interpersonal relationships. GAF scores between 71 and 80 are indicative of symptoms which, if present, are transient and expectable reactions to psychosocial stressors (e.g. difficulty concentrating after a family argument), with no more than slight impairment in social, occupational, or school functioning (e.g. temporarily falling behind in schoolwork). GAF scores between 81 and 90 are indicative of absent or minimal symptoms (e.g. mild anxiety before an examination), good functioning in all areas, interest and involvement in a wide range of activities, social effectiveness, general satisfaction with life, and no more than everyday problems or concerns (e.g. an occasional argument with family members). There is no question that a GAF score and its interpretations are important considerations in rating a psychiatric disability. However, the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the percentage disability rating issue; rather, a GAF score must be considered in light of the actual symptoms of the veteran's service-connected disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). In this case, the medical evidence of record fails to show that the veteran's service-connected PTSD symptoms include chronic impairment in reality testing or communication, major impairment in family relations, judgment, thinking, or mood, suicidal ideation, severe obsessional rituals, frequent shoplifting, a complete lack of friends, inability to keep a job, or theft within the household. Although the veteran has occasional panic attacks, a depressed mood and difficulty concentrating at times, and some difficulty in social and occupational functioning, he generally functions effectively in a wide range as an evangelical minister, and has some meaningful interpersonal relationships. Moreover, the Board notes that the August 2002 GAF score of 40 and the January 2004 GAF score of 50 were assigned on the basis of the veteran's combined physical and mental disorders, including significant diabetes and severe osteoarthritis of the spine and knees, and were not solely attributable to the PTSD. Additionally, the Board finds that there is no showing that, at any point since the effective date of the grant of service connection, the veteran's PTSD has reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher rating on an extraschedular basis pursuant to the provisions of 38 C.F.R. § 3.321(b)(1). The veteran's symptoms and clinical findings as documented in extensive medical reports from 2002 to 2007 do not objectively show that his PTSD markedly interferes with employment (i.e., beyond that contemplated in the assigned rating throughout this period), or requires frequent periods of hospitalization, or otherwise renders impractical the application of the regular schedular standards. In this regard, the Board notes that Dr. J. S.'s August 2002 opinions that the veteran's condition would continue to deteriorate and that he was unable to work included consideration of his significant physical disabilities, namely diabetes and severe osteoarthritis of the spine with natural fusion, and were not solely due to the PTSD. The SSA in October 2002 found the veteran disabled from September 2001 solely due to physical disabilities of osteoarthrosis and allied disorders, and discogenic and degenerative disorders of the back; his PTSD was not a factor in the disability determination. In November 2002, Dr. D. O. noted the veteran's disabilities including PTSD, but that he had to quit a job as a roofer only due to physical disabilities of the right hip and thoracic spine, not PTSD. The January 2003 VA psychiatric examiner noted that the veteran was currently employed as an evangelist, traveling extensively and working and praying with people with drug and alcohol problems, and that he had had to abandon training as a chef last year solely due to knee problems, not his PTSD. The January 2004 VA examination noted that the veteran had not worked for 2 years due to knee problems, not PTSD. April 2005 VA occupational therapy evaluation noted that the veteran's community activity was limited by knee pain, not his PTSD. The February 2006 VA examination noted that, since 1990, the veteran had done evangelistic work, praying for people, visiting them in hospitals, counseling those with marital, drug, and alcohol problems, and preaching once or twice per month. The Board notes periods of VA hospitalizations for disabilities including PTSD from August to October 2005 and from June to July 2007, but that these hospitalizations were also concerned with detoxification as a result of medication abuse and subsequent medication stabilization. Under the circumstances, the Board finds that a schedular rating is adequate in this case, and concludes that the criteria for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board finds that there is no basis for staged rating pursuant to Fenderson, and that the claim for an initial rating in excess of 30% for PTSD must be denied. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53- 56 (1990). ORDER An initial rating in excess of 30% for PTSD is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs