Citation Nr: 0813994 Decision Date: 04/29/08 Archive Date: 05/08/08 DOCKET NO. 04-28 672A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to a higher disability rating for service- connected post traumatic stress disorder (PTSD), currently rated 50 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD K. Curameng, Associate Counsel INTRODUCTION The veteran who had active duty service from January 1945 to July 1948, with subsequent service in the reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2003 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The veteran's notice of disagreement was received in February 2004. A statement of the case was issued in April 2004, and a substantive appeal was received in August 2004. In February 2008, the veteran's representative submitted a motion to have the case advanced on the docket due to the veteran's advanced age. The motion was granted by the Board in April 2008 pursuant to 38 U.S.C.A. § 7107 (West 2002); 38 C.F.R. § 20.900(c) (2007). Further, the veteran had perfected an appeal for a claim of entitlement to service connection for ulcers. In a December 2007 statement from the veteran, it was noted that the claim for ulcer is being withdrawn. The issue is therefore no longer in appellate status. By rating decision in December 2003, the RO granted service connection for PTSD, and assigned a 30 percent disability rating, effective September 19, 2002. The veteran appealed the disability rating assigned. In a November 2006 rating decision, the RO assigned a 50 percent disability rating, effective January 15, 2004. Although an increased rating has been granted, the issue remains in appellate status, as the maximum schedular rating has not been assigned. AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. Prior to January 15, 2004, the veteran's service- connected PTSD was manifested by depressed mood and chronic sleep impairment. 2. From January 15, 2004, the veteran's service-connected PTSD has been manifested by disturbances of motivation and mood, and difficulty in establishing and maintaining effective social relationships. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability evaluation in excess of 30 percent prior to January 15, 2004, for the veteran's service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2007). 2. The criteria for entitlement to a disability evaluation in excess of 50 percent from January 15, 2004, for the veteran's service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). VA must request that the claimant provide any evidence in the claimant's possession that pertains to a claim. 38 C.F.R. § 3.159. The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant pre-adjudication notice by a letter dated in November 2002 regarding the veteran's service connection claim for PTSD. The notification substantially complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and Pelegrini v. Principi, 18 Vet. App. 112 (2004), requesting the claimant to provide evidence in her possession that pertains to the claim. The RO also provided the appellant with notice in December 2005, subsequent to the December 2003 adjudication. The notification substantially complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and Pelegrini v. Principi, 18 Vet. App. 112 (2004), requesting the claimant to provide evidence in her possession that pertains to the claim. While the December 2005 notice was not provided prior to the December 2003 adjudication, the claimant has had the opportunity to submit additional argument and evidence, and to meaningfully participate in the adjudication process. The claim was readjudicated in a November 2006 supplemental statement of the case, following the provision of notice. The veteran and her representative have not alleged any prejudice as a result of the untimely notification, nor has any been shown. Regarding the issue of a higher disability rating for PTSD, the Board acknowledges the decision of the United States Court of Appeals for Veterans Claims (Court) in Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008) which noted that for an increased-compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. The Court further indicated, among other things, that if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), VA must provide at least general notice of that requirement to the claimant. However, the Board believes that the nature of the present appeal is somewhat different from the situation addressed in Vasquez-Flores. The present appeal involves the issue of a higher initial rating, not a claim for an increased rating. A review of the record shows that the RO, in connection with the veteran's original service connection claim provided the veteran with adequate VCAA notice in a November 2002 letter prior to the December 2003 adjudication of the claim which granted service connection. In Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006), the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. 5103(a) (West 2002), notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Also see Hartman v. Nicholson, 483 F.3d 1311, 1314-1315 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-117 (2007). In line with the reasoning set forth in these judicial decisions, it appears that the notice requirements addressed by the Court in Vasquez-Flores, supra, do not apply to initial rating claims such as the one now on appeal to the Board. Duty to Assist VA has obtained service and VA medical records. The veteran was also afforded VA examinations in April 2003 and March 2006. All known and available records relevant to the issues on appeal have been obtained and associated with the veteran's claims file; and the veteran and her representative have not contended otherwise. VA has substantially complied with the notice and assistance requirements and the veteran is not prejudiced by a decision on the claim at this time. Increased Ratings The present appeal involves the veteran's claim that the severity of her service-connected PTSD warrants a higher disability rating. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. Under the criteria for PTSD (set forth at 38 C.F.R. § 4.130, Diagnostic Code 9411), a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for 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 assigned 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 work-like setting); inability to establish and maintain effective relationships. A 100 percent schedular rating 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 relative, own occupation or own name. The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). According to the DSM-IV, a GAF score between 41 and 50 is 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, unable to keep a job); a GAF score between 51 and 60 is indicative of 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 coworkers). Factual Background An April 2002 VA mental health initial intake shows that when asked if there was a history of suicidal/homicidal ideation or history of assaultive behavior, none were listed. The veteran's hygiene, attire, eye contact were deemed appropriate. Response to the examiner was described as cooperative. Affect was deemed within normal range and mood was observed as sad. Memory was described as unimpaired, and cognition and insight were deemed intact. Impulse control was determined as good. The diagnosis was major depressive disorder with a GAF score of 60. She was then seen in June 2002 and denied suicidal ideation and homicidal ideation. She did report having a feeling of amotivation in that she would normally be very excited to see her daughter, but believed it was so much trouble to go see her out of state. When the veteran complained of forgetfulness, a mini-mental state examination (MMSE) was conducted and she scored a 30 out of 30. It was noted that she was alert and oriented in all four spheres and slept without difficulty. Her speech was deemed within normal limits. Her mood was described as euthymic and her affect was described as broad. It was noted that no psychosis was observed. When the veteran was seen in August 2002, she was described as alert and oriented in all four spheres. Speech was described as within normal limits and mood seemed slightly dysphoric and worried. Affect was described as sufficiently broad. She denied suicidal ideation, homicidal ideation, auditory hallucinations and visual hallucinations. When an MMSE was administered, she scored a 30 out of 30. The assessment was mild depressive disorder recurrent with recent stressors. The veteran was seen on several occasions from August 2002 to September 2002 at the Vet Center for individual counseling. Altogether the assessments reflected PTSD symptoms (intrusive thoughts, hearing Morse Code sounds); health issues; isolation (with only social activity riding bus with other veterans to attend medical and counseling appointments); depression; memories from the military; sleep disturbance; anger issues; trust issues; and problems with authority. The veteran was later seen in September 2002 for follow up on depression. It was observed that she was alert and oriented in all four spheres; and that she was described as engaging and very pleasant. It was noted that her speech was spontaneous and that she slept well. Her mood was described as euthymic to slightly dysphoric. Her affect was noted as congruent. She denied suicidal ideation, homicidal ideation, visual hallucinations, and auditory hallucinations. The assessment was mild depressive disorder that was much improved. An October 2002 letter from the Vet Center shows that the veteran reported anger/rage, flashbacks, reoccurring dreams, sleep disturbance, startle responses, authority issues, lack of intimacy (estranged from both daughters), problems with impulse control, and isolation/avoidance (had few friends, never remarried, and engaged in social activities with veterans). The diagnoses was chronic and enduring PTSD with a GAF score of 55. Additional October 2002 Vet Center records altogether show an assessment of decreased depression; anxiousness; sleep disturbance; health issues; increased nightmares; and more memories regarding events experienced in the military. The veteran was seen again in November 2002, and she denied suicidal ideation and homicidal ideation. She reported that she was doing well with no signs of depression. She further reported sleeping well and going to the Vet Center. She was described as alert and oriented in all four spheres, engaging, and smiling. She was further described very pleasant overall. Her sleep was noted as okay and her speech was observed as within normal limits. Her mood was deemed euthymic and her affect was deemed broad. It was further noted that there were no signs of psychosis. The assessment was mild depressive disorder in remission. A November 2002 Vet Center record reveal assessments of hyperalertness, depression, and good communication with one of her daughters. And a December 2002 Vet Center entry reveals an assessment that included an increase in PTSD symptoms-hyperalertness and sleeping difficulties. A January 2003 VA medical record shows that the veteran reported that her major depressive disorder symptoms were getting better and reported decreased concentration, energy, appetite, guilt, and anhedonia. She denied suicidal ideation and there were no motor retardation. She further reported flashbacks and nightmares. The assessment was provisional PTSD. The veteran was again seen in March 2003. The veteran reported that she was doing worse since the Gulf War and was having nightmares, flashbacks with depression on some days that she described as horrible. It was noted that the veteran was pleasant and cooperative with good eye contact. It was further noted that she was sometimes appropriately tearful when discussing certain topics. Affect was noted as full. She reported waking up to a trash truck banging cans and beeping during backing up which made her think that she was aboard a ship during an alarm. Thought process was described as linear. The veteran denied suicidal and homicidal ideation. She had intrusive thoughts of Pearl Harbor (when her boyfriend had died on the USS Arizona) that worsened with the events of September 11, 2001 and the war in Iraq. She was encouraged to get involved in the PTSD group at the Vet Center. The veteran was seen on two occasions for individual counseling in March 2003 and reported issues with one of her daughters. Altogether, the assessments reflected health issues, anxiety, sleep disturbance, nightmares, anger, and social isolation. When the veteran was afforded a VA examination in April 2003, the VA examiner observed that the veteran was nicely groomed, pleasant and cooperative. It was further observed that the veteran was able to laugh and smile appropriately throughout the interview and the interpersonal relationship with the VA examiner was deemed good. It was also observed that she was spontaneous, coherent, and relevant showing no major psychomotor retardation that was noticeable. The VA examiner stated that there was some constriction of the veteran's affect of display to a mild degree, but it was not at all major that would make one think of any kind of major depressive disorder. The veteran reportedly had suicidal ideation two months ago related to her daughter calling and becoming angry with her. She described loss of interest and lack of energy. She continued that she had occasional crying spells, but still enjoyed swimming and backpacking. It was noted that the veteran did not show any kind of psychotic disorder and that there were no auditory and visual hallucinations or any kind of referential thoughts. Her sensorial, mental grasp, and capacity were described as very clear particularly for her age. The VA examiner noted that she was able to correctly say the date and even though she complained of "short-term memory loss," she remembered 3 out of 3 objects after five minutes. Insight and judgment were deemed excellent particularly for her age. The VA examiner continued that there did not appear to be any significant impairment in her thought processes or communication and there was no evidence of delusions or hallucinations. Eye contact and interaction were described as quite appropriate. It was additionally noted that the veteran had suicidal thoughts in the past, but no homicidal thoughts. It was further noted that she never attempted suicide or homicide. The VA examiner continued that the veteran was able to maintain her minimal personal hygiene was able to dress and bathe herself. The veteran was able to cook, shop, ride a bus, and tried working out in a chair. It was also noted that she was oriented to time, place, and person. The VA examiner noticed that her mental status examination did not show marked short-term memory loss as reported by the veteran. It was additionally noted that she did not show obsessive or ritualistic behavior, and her rate and flow of speech was logical and relevant. The VA examiner also stated that the veteran did not exhibit panic attacks. The veteran complained of depressed mood. It was noted that she had no impaired impulse control or loss of anger. The veteran stated that on most nights she slept seven to eight hours a night, but had nightmares three times a month which resulted in only five hours of sleep. The VA examiner noted that the veteran had a mood disorder in addition to PTSD with no other substance abuse or anxiety disorders. The VA examiner diagnosed PTSD with a GAF score of 60. Various April 2003 to June 2003 reports from the Vet Center show individual supportive counseling with assessments of relationship problems with her daughter, depression, sleep disturbance, nightmares, health issues, anger, agitation, frustration, and anxiety. VA medical records from June 2003 show that the veteran was well-groomed, pleasant and cooperative with full affect. She denied auditory and visual hallucinations. It was noted that she was alert and oriented in all four spheres. Thought process was deemed linear and good. The veteran denied suicidal and homicidal ideations. The assessment was PTSD, dysthymia. Various July 2003 to December 2003 reports from the Vet Center show individual supportive counseling with assessments of isolation, avoidance of friends, intrusive thoughts, sleep disturbance, nightmares, family discord, health issues, anxiety, depression, frustration, and memories of sexual harassment in the military. A January 15, 2004 report from the Vet Center shows that the veteran arrived as scheduled and appeared less depressed than the previous session. Regarding the December 2003 RO decision on her claim, she reported feeling better that the government finally realized how her military service affected her life. She noted that she was going to appeal and address the issues that were left out such as problems with relationships (not having a serious one since the 1960's and little contact with one of her daughters since the 1970's). She reported having a more difficult time being around others, and feeling angry and irritable. Discussed were reasons for her anger and ways to deal with it without isolating herself so much. She agreed to go to the next American Legion monthly meeting. She stated that she was reluctant about calling or visiting any of her old friends. The assessment was anger, isolation, depression, and continuing medical problems. The plan was that she would continue individual supportive counseling to encourage her to stop isolating and avoiding others, and that she would work on the relationship with her one daughter whom she talks to sporadically. The veteran reported no desire to talk to the eldest child, who she had not seen since 1974. VA medical records from January 2004 show that the veteran's daughter asked her to live with her, but the veteran did not want to because her daughter was often rude to her. She was described as well-groomed, clean casual dress. She was further described as pleasant and cooperative with high production speech with normal rate and no obvious pressuring. Psychomotor activity was within normal limits and mood was described as "bad." Her affect was noted as euthymic, and her thoughts were deemed circumstantial/tangential. Noted were no delusions. She denied suicidal ideation. She was observed as alert, and her memory and concentration were described as grossly intact. Insight and judgment were noted as fair. The assessment was PTSD, depression not otherwise specified. She was seen later in February 2004 and was described as well-groomed, clean casual dressed, pleasant and cooperative with high production speech at a normal rate with no obvious pressuring. Psychomotor activity was deemed within normal limits, and her mood was deemed worse. It was noted that her affect seemed euthymic and her thoughts were circumstantial and tangential. Noted where no delusions. The veteran denied suicidal ideation. When asked about having thoughts of harming others, she said that thoughts of harming others developed if others aggravated her. It was observed that she was alert, and that her memory and concentration were grossly intact. Her insight and judgment were deemed fair. Part of the assessment was PTSD with exacerbation of anger, possibly due to increased stressors, increased depression. Various February 2004 to April 2004 reports from the Vet Center show individual supportive counseling with assessments of depression, sleep disturbance, isolation, intrusive thoughts, anger/rage, and worsening of health. VA medical records from May 2004 show that she was well- groomed, clean casual dress, pleasant and cooperative. She had high production speech with normal rate and no obvious pressuring. Psychomotor activity was deemed within normal limits. Her affect seemed euthymic and mood noncongruent. Thoughts were described as circumstantial and tangential. Noted were no delusions. Also noted was that she was alert, and that her memory and concentration were grossly intact. The assessment was PTSD with some exacerbation possibly due to recent stressors. A May 2004 report from the Vet Center show individual supportive counseling with assessments of depression, anger, isolation, and nightmares. The veteran was seen again in July 2004 and was described as well groomed; and noted was a stain on the chest of her shirt. She was deemed pleasant and cooperative with high production speech with normal rate and no obvious pressuring. Psychomotor activity was deemed within normal limits. It was noted that affect seemed dysphoric with mood reactivity (smiling appropriately at times). Her thoughts were deemed circumstantial and noted were no delusions. She denied suicidal ideation and denied not report homicidal ideation. It was additionally noted that there was no evidence of psychosis. She was described as alert with memory and concentration grossly intact. The assessment was PTSD. An August 2004 updated assessment from the Vet Center shows that the veteran reported rage/anger, depression, nightmares, sleep disturbance, intrusive thoughts, avoidance of crowds, relationship problems (she divorced in 1957 and never remarried; she had two significant relationships, but both men died; she was estranged from her oldest daughter and her sister; and she had a sporadic relationship with her younger daughter) problems with intimacy, lack of trust, physical ailments, isolation (lost interest in past activities and clubs and stopped attending most gatherings except for monthly veteran's group), startle responses, few friends, anxiety, and resentment against Japanese people. The assessment shows a diagnosis of chronic PTSD and a GAF score of 48. The veteran was seen for individual counseling at the Vet Center in November 2004 and the assessment was depression; estrangement from family; health issues; and isolation. December 2004 VA medical records show that she was social in the waiting area and somewhat talkative. Psychomotor activity was deemed within normal limits. It was noted that her affect had full range and that thought process could be circumstantial with no evidence of psychosis or cognitive impairment. The assessment was PTSD. A VA treatment record from February 2005 reveals that the veteran reported that her depression remained the same. The veteran also revealed that she was an executive member of American Legion that met weekly. She denied any suicidal and homicidal ideation. Psychomotor activities were deemed slow. Affect was described as full and thought process was described as circumstantial. There was no evidence of psychosis and the veteran denied auditory and visual hallucinations. Her cognition was deemed intact, and she was described as alert and oriented in all four spheres. The assessment was PTSD. The veteran was seen again in June 2005, and it was noted that she had recurrent, chronic mild depressive disorder. She reported that she was once suicidal, but not now. She reported intrusive memories of war with nightmares experienced 2 to 3 times a month. She said she had trouble falling and staying asleep. She further said she experienced hypervigilance rituals, increased irritability, increased anger, decreased patients, decreased short-term memory concentration, exaggerated startle response. She continued that she isolated herself and that she felt depressed and sad, but mostly angry. She described herself as anhedonic and anergic. She stated that her self esteem was okay. There was decreased sleep, fair appetite, and no suicidal and homicidal ideation. She also reported no psychosis. She reported having passive thought of death/dying and has felt hopeless and depressed about her diplopia. The veteran was described as casually and appropriately dressed. She was also described as engaged with eye contact with one eye. She was further described as cooperative and slightly agitated. Speech was described as spontaneous. Mood was observed as angry and depressed. Affect was described as congruent. She was noted as being alert and oriented in four spheres and her cognition was deemed intact. The assessment was moderately severe PTSD. VA treatment records from October 2005 show that she was dressed neatly, casually and appropriate. She was described as having good eye contact and remained cooperative and calm. Speech was described as spontaneous. Mood was described as depressed and affected was restricted. There was no suicidal ideation, homicidal ideation, or psychosis. She was alert in all four spheres and cognition was deemed intact. The assessment was PTSD. A January 2006 updated assessment from a VA social worker shows that the veteran reported rage/anger; depression; nightmares; sleep disturbance; intrusive thoughts; irritability; avoidance of grounds; relationship problems (the Board notes that although she was estranged from her eldest daughter, it was noted that she developed more of a relation with her youngest daughter since counseling); problems with intimacy; lack of trust; physical ailments; isolation (still attending a monthly veterans' group); startle responses; few friends; anxiety; and resentment against Japanese. The diagnosis was chronic PTSD with a GAF score of 48. The veteran was afforded another VA examination March 2006. It was noted that the veteran was casually dressed and reasonable groomed with adequate hygiene. It was additionally noted that she was cooperative with information and her affect was blunted. Her speech was deemed circumstantial. She intimated that she still tried to attend American Legion meetings every month and that she was on the Executive Board of the American Legion volunteering as the bookkeeper/accountant. She explained that she was unable to engage in quilting, painting, and reading like she once did because of strabismus related to a paralyzed cranial nerve. June 2006 Vet Center records reflect assessments that included serious PTSD, nearly groomed hair, spontaneous speech, sad but stable mood and affect, and oriented in three spheres. I. Prior to January 15, 2004 The Board believes that PTSD symptomatology does not reflect a rating in excess of 30 percent prior to January 15, 2004. While it appears that there are disturbances of motivation and mood, the veteran did not have the majority of symptoms required to warrant a rating of 50 percent. Here, while there was difficulty in establishing and maintaining effective social relationships, as noted above, in October 2002 she did report having a few friends and engaged in social activities with veterans. And while she reported having short-term memory, the medical evidence from June 2002 and August 2002 showed that she had a perfect score when the MMSE was administered; and an April 2003 VA medical record showed that she remembered 3 out of 3 objects after five minutes. Additionally, there is no medical evidence of flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; and difficulty in understanding complex commands. In addition, there was no impairment of long-term memory given that an April 2002 VA medical record shows that her memory was described as unimpaired and given that she continually recalled events that she experienced in the military. Moreover, the medical evidence of record did not reflect impaired judgment; and impaired abstract thinking to warrant a rating of 50 percent. A rating of 70 percent is not warranted as well. The medical of evidence of record did not reflect obsessional rituals which interfere with routine activities; and she did not have speech that was described as intermittently illogical, obscure, or irrelevant. Moreover, there was no near- continuous panic. And while she was battling depression, it did affect her ability to function independently, appropriately and effectively--she lived on her own, and was usually described as pleasant and cooperative with good eye contact. Although in November 2002 she reported impaired impulse control (such as unprovoked irritability with periods of violence), the veteran did not exhibit the majority of symptoms that would warrant a 70 percent rating. Here, there was no medical record reflecting spatial disorientation. Further, there was no neglect of personal appearance and hygiene as she was described as well-groomed, clean casual dress. And there was no evidence that she had difficulty in adapting to stressful circumstances as she was able to cook, shop, ride a bus, and work out. In addition, the veteran did not exhibit the inability to establish and maintain effective relationships to warrant a rating of 70 percent. Again, according to the veteran in October 2002, she had a few friends and engaged in social activities with veterans. And, at the April 2003 VA examination, it was noted that the interpersonal relationship with the VA examiner was deemed good. And there was no medical evidence of record showing 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 relative, own occupation or own name to warrant a rating of 100 percent. She continually denied delusions or hallucinations. VA medical records show that she was pleasant and while there were some reports that she had been suicidal in the past, there was no indication of persistent danger of hurting herself. And there was no indication of persistent danger of hurting anyone else. Further, as noted above, she maintained her personal hygiene. Additionally, she was always described as alert and oriented in all four spheres. The potential application of various provisions of Title 38 of the Code of Federal Regulations have also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). In this regard, the Board finds that there has been no showing by the veteran that the service connected disability has resulted in marked interference with employment or necessitated frequent periods of hospitalization. In the absence of such factors, the Board finds that criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Additionally, GAF scores ranged from 55 to 60, which are indicative of moderate symptoms that are reflected in a rating of 30 percent. II. From January 15, 2004 The Board believes that PTSD symptomatology does not reflect a rating in excess of 50 percent from January 15, 2004. The veteran did not exhibit the majority of symptoms that would warrant a 70 percent rating. Here, there was no medical record reflecting impaired impulse control spatial disorientation. Moreover, there was no neglect of personal appearance and hygiene as she was continually described as well-groomed, clean casual dress; and the most recent report in June 2006 showed that she had nearly groomed hair. And it did not appear that she difficulty in adapting to stressful circumstances as she was an executive board member of the American Legion acting as their bookkeeper/accountant. In addition, the veteran did not exhibit the inability to establish and maintain effective relationships to warrant a rating of 70 percent. The Board acknowledges statements made by the veteran in January 2004 when visiting the Vet Center that she had not been in a romantic relationship since the 1960's and that she was not in touch with one of her oldest daughter since the 1970's. And she reported isolating herself. However, the medical records reflect the veteran reporting that she was sporadically in touch with her youngest daughter, and that she attended monthly American Legion meetings. Also, a December 2004 VA medical record revealed that she was social while in the waiting area and appeared somewhat talkative. And there was no medical evidence of record showing 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 relative, own occupation or own name to warrant a rating of 100 percent. Again, she continually denied delusions or hallucinations. VA medical records show that she was pleasant, and there was no indication of persistent danger of hurting herself or anyone else. And it appears to the Board that she always maintained her personal hygiene. Additionally, she was typically described as alert and oriented. Her memory was continually described as "grossly intact." The Board does acknowledge that a June 2006 Vet Center record reflects an assessment of serious PTSD, and that her GAF scores have been as low as 48, which is indicative of serious symptoms that are reflected in a rating of 70 percent. And while she had mentioned suicidal ideation in the past, there were no severe obessional rituals or serious impairment in social and occupations function in which she had no friends or was unable to keep her position as bookkeeper/accountant for the American Legion. Again, the veteran reported having few friends, being in touch with her youngest daughter, and taking an active role in the American Legion. Thus, a rating in excess of 50 percent is not warranted. The potential application of various provisions of Title 38 of the Code of Federal Regulations have also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). In this regard, the Board finds that there has been no showing by the veteran that the service connected disability has resulted in marked interference with employment or necessitated frequent periods of hospitalization. The Boards notes that the veteran has been able to maintain her position as a board member of the American Legion acting as a bookkeeper/accountant. Thus, the Board finds that criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board notes that the veteran may always advance an increased rating claim if the severity of her PTSD should increase in the future. ORDER The appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs