Citation Nr: 0814129 Decision Date: 04/29/08 Archive Date: 05/08/08 DOCKET NO. 04-17 361 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD Thomas H. O'Shay, Counsel INTRODUCTION The veteran had active military service from April 1966 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a November 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. The Board remanded this case in July 2007 for further development. Although the issue of service connection for tinnitus was developed for appellate review, service connection for that disorder was granted in September 2007 while the appeal was in remand status. That issue therefore is no longer before the Board. In July 2007, the Board denied service connection for low back disability. In December 2007, the Board denied the veteran's motion for reconsideration of the July 2007 decision. If he wishes to submit an application to reopen the issue of service connection for low back disability, he should so notify the RO. In February 2007, the veteran withdrew his request for a Board hearing. The Board lastly notes that in the July 2007 decision, the Board referred the issue of entitlement to a total rating based on individual unemployability due to service-connected disabilities for appropriate consideration. Inasmuch as the RO has not taken any action on this referral, the Board again refers the issue of entitlement to a TDIU to the RO for appropriate action. FINDING OF FACT The veteran's PTSD is manifested by substantial impairment in the ability to establish or maintain effective or favorable relationships with people; but not by serious or severe impairment in such ability, by at least severe or pronounced impairment in the ability to obtain or retain employment, by virtual isolation in the community, by totally incapacitating psychoneurotic symptoms, by total occupational impairment, or by occupational and social impairment with reduced reliability and productivity or deficiencies in most areas. CONCLUSION OF LAW The criteria for a 50 percent evaluation for PTSD have been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1987); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1995); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2007). REASONS AND BASES FOR FINDING AND CONCLUSION Under 38 U.S.C.A. § 5103, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate the claim, and of which information and evidence that VA will seek to provide and which information and evidence the claimant is expected to provide. Furthermore, in compliance with 38 C.F.R. § 3.159(b), the notification should include the request that the claimant provide any evidence in his possession that pertains to the claim. In the present case, and prior to the establishment of service connection for the veteran's PTSD, VA provided the veteran with the notice contemplated by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) in a September 2001 correspondence. The correspondence did not provide him with notice of the information and evidence necessary to substantiate the initial rating and the effective date to be assigned a grant of service connection in the event his PTSD claim was successful. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Once, however, his claim was substantiated through the grant of service connection and he was assigned an initial disability rating and effective date for the grant of service connection in November 2002, VA had no further notice obligations under 38 U.S.C.A. § 5103(a) with respect to the veteran's disagreement with the initial rating assigned. The record reflects that he did receive the notice to which he is entitled under 38 U.S.C.A. §§ 5103A and 7105, including through the issuance of a statement of the case. See Dingess/Hartman, 19 Vet. App. at 490-91. In any event, the veteran was provided with notice as to the two referenced elements in March 2006 and July 2007 correspondences. His claim was thereafter readjudicated in a December 2007 supplemental statement of the case. For the above reasons, the Board finds that VA's notification duties have been met in this case. The Board notes that the United States Court of Appeals for Veterans Claims (Court), in Vasquez-Flores v. Peake, 22 Vet. App. 37 (2008) clarified VA's notice obligations in increased rating claims. The instant appeal originates, however, from the grant of service connection for the disorder at issue. Consequently, Vasquez-Flores is inapplicable. Based on the procedural history of this case, it is the conclusion of the Board that VA has complied with any duty to notify obligations set forth in 38 U.S.C.A. § 5103(a). With respect to VA's duty to assist the veteran, the Board notes that pertinent records from all relevant sources identified by him, and for which he authorized VA to request, were obtained by the RO or provided by the veteran himself. 38 U.S.C.A. § 5103A. In this regard, the veteran has reported receiving counseling for his PTSD at a Westwood or "West LA" Vet Center from 1984 through 1987. Although those records are not on file, he has not authorized VA to obtain such records. The Board points out in this regard that VA does not maintain a "Westwood" or "West LA" Vet Center in California or any other state, and that the veteran has not otherwise provided sufficient address information to identify the facility as one operated by VA. Moreover, he admittedly was employed on a full time basis during that period, and does not contend that his symptoms were worse during that period than they have been in recent years. To the contrary, he argues that his current symptoms are now worse. After reviewing the veteran's statements and other evidence of record, the Board finds that the evidence on file is adequate for the purpose of fairly adjudicating his claim. The Board also notes that the veteran claims to have documents showing that he would have been fired from his last Federal job if he had not decided to retire. Notably, however, he has not provided VA with that evidence. The record shows that the veteran has been advised to submit pertinent evidence in his possession. If he feels the referenced evidence (by his account, documents showing revocation of flexi-place approval, denial of a within-grade increase, and a performance appraisal), supports entitlement to an increased evaluation for his PTSD, he is free to submit it in the context of a claim for an increased rating. The record also reflects that the veteran was afforded several VA examinations in connection with the appeal. In sum, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Therefore, the veteran will not be prejudiced as a result of the Board proceeding to the merits of the claim. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). In accordance with 38 C.F.R. §§ 4.1, 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the veteran's service-connected PTSD. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2007). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two evaluations should 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. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Fenderson v. West, 12 Vet. App. 119 (1999), however, it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then-current severity of the disorder. Further, in Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Factual background Service connection for PTSD was granted in a November 2002 rating decision, with an initial assigned evaluation of 30 percent effective August 9, 2001. The 30 percent evaluation has remained in effect since that time. In an October 2004 rating decision, the RO determined that a December 1984 rating decision was clearly and unmistakably erroneous in failing to recognize and grant an implied claim for service connection for PTSD; the October 2004 rating decision awarded the veteran an effective date for the grant of service connection for PTSD (and for the assignment of a 30 percent evaluation) of July 10, 1984. The service medical records show that the veteran sustained a head injury. Psychological testing was consistent with mild residual organic impairment, with the most obvious manifestation in his impaired ability to concentrate. He was discharged as unfit for duty secondary to encephalopathy. VA treatment records for 1983 to May 2006 show that depression screenings in 2000 were negative. Records for 2001 show that he consistently denied suicidal or homicidal ideation. His psychiatric complaints included nightmares once per month, intrusive thoughts, relationship difficulties, hyervigilance, and anger. He reported that he pushed his spouse recently, although he noted that she had assaulted him in the past, and indicated that they were in marital counseling. He reported concentration difficulties he was able to cover up at work, and reported social isolation. Mental status examination showed that he had adequate hygiene, normal motor activity, normal speech, normal thought content, normal memory and perception, a dysphoric mood, and a constricted affect. He was alert and oriented, with no impairment in the ability to abstract. His judgment was intact. His assigned Global Assessment of Functioning (GAF) score was 55, and he was thought to have moderate to severe psychiatric symptoms, with severe relationship difficulties. Records for 2002 additionally document anger problems, and for 2003 and 2004 show that he was working full time, with complaints including irritability and one episode of road rage; his anger and mood symptoms improved with medication, and he was alert and oriented with intact judgment on mental status examination. Subsequent records show he denied suicidal or homicidal ideation. At a July 10, 1984, VA examination, the veteran complained of nightmares, apathy, and episodes of rage. Mental status examination showed that he was alert and oriented, with unimpaired memory. His ability to abstract was considered normal, as were his judgment and affect. At a December 1999 VA examination, the veteran presented as well groomed, alert and oriented. His mood was irritable and his affect restricted. His speech was normal. His psychiatric complaints included past intrusive recollections and nightmares. He also reported memory problems, depression, lack of feelings, lack of motivation, and family problems. He denied suicidal or homicidal ideation. Psychological testing revealed average to superior functioning in all areas. The veteran attended a VA examination in June 2003. He reported that he had been employed on a full time basis since 1984, and that he worked from home. He indicated that he worked well with his coworkers under the current arrangement, but believed that his supervisor "was out to get him." He explained that he had been married to his current spouse since 1983, but that his marriage was characterized by anger issues and counseling. He described one instance of a mutual assault occurring several years before, which his spouse initiated. He indicated that he had good relationships with two of his children, but stayed alone most of the time and had no close friends. He complained of regular nightmares, depression, problems with controlling his anger, lack of feelings and motivation, difficulty when in groups and in getting along with associates, confusion, difficulty concentrating, memory problems, and hypervigilance. The examiner noted that the veteran's GAF scores since 2001 suggested mild to moderate impairment in psychological, social, and occupational functioning. He also noted that the veteran admitted to occasional fleeting suicidal thoughts, the last one occurring two months previously. He also admitted to occasional violent thoughts but denied any associated action or plan; his last violent thought occurred over two years previously, and he denied any homicidal ideation. He indicated that his symptoms have varied in severity since service, and he believed his symptoms had resulted in strained marital and interpersonal relationships. Mental status examination showed that he was depressed and irritable. He was alert and oriented, and was appropriately dressed with adequate hygiene. His social skills were fair, and his concentration was intact. His speech was normal. His affect was constricted, but appropriate. His memory was intact. He exhibited no psychomotor abnormalities. His thought processes were logical, and his reasoning was sufficiently abstract. He displayed no abnormal thought content. His judgment was intact. Psychological testing was considered invalid. The examiner concluded that the veteran's symptoms caused moderate difficulty in social and occupational functioning. He assigned the veteran a GAF score of 60. At a June 2006 VA examination, the veteran reported that his past marriages were turbulent, although he noted that his current marriage was stable. He reported that he received vocational and college training, and had worked for the equivalent of 34 years. He indicated that he was never close to his coworkers, but had gotten along with them. He did not get along with any supervisor. He complained of depression, anger, anxiety, frequent flashbacks, and nightmares. He reported experiencing trouble sleeping and difficulty with feeling. He avoided reminders of service, but nevertheless thought about his service experiences daily. He explained that he was uncomfortable in groups and had trouble getting close to family. He reported experiencing suicidal thoughts, and noted that he had trouble holding down jobs. He also noted that he had few friends, and he reported symptoms including restricted range of affect, emotional numbing, intrusive recollections, psychogenic amnesia, feelings of detachment, social isolation, confusion, and problems with concentration and attention. Mental status examination showed that his mood was anxious and depressed, but oriented. His affect was appropriate. His speech was normal. He was concrete in the progression of his thoughts and labile, with no unusual mannerisms or psychotic manifestations. He denied hallucinations, delusions or ideas of reference. The examiner considered the veteran's level of impulse control to be poor. He denied any current suicidal ideation or plan. His memory was normal, and his judgment was good. The examiner assigned a GAF score of 51. The examiner noted that in the past year, the veteran's PTSD symptoms had worsened and had compromised his activities of daily living. He noted that the veteran had difficulty making decisions, and experienced difficulty in interpersonal relationships. In several statements, the veteran notes that he had attended therapy intermittently since 1984. He explained that he experienced uncontrollable fits of rage when provoked. As to employment, he explained that he worked for 34 years before being forced to resign in December 2004, but had begun having trouble at work in 1999 after his job tasks changed in approach; he clarified that prior to 1999, he would win awards for his performance. The veteran indicated that he had been fired by four employers since he retired, and experiences symptoms including difficulty in understanding complex commands, impaired memory, and disturbances of motivation and mood. He also indicated that he experiences difficulty in maintaining effective work and social relationships. Analysis As noted previously, the RO established July 10, 1984, as the effective date of the award of service connection for PTSD. The rating criteria for PTSD in effect from July 1984 through February 2, 1988 provided that PTSD warranted a 30 percent rating for definite impairment in the ability to establish or maintain effective and wholesome relationships with people. The psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency and reliability levels as to produce considerable industrial impairment. A 50 percent rating was warranted when the ability to establish or maintain effective or favorable relationships with people is substantially impaired; and where, by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels are so reduced as to result in severe industrial impairment. A 70 percent rating was warranted when the ability to establish and maintain effective or favorable relationships with people is seriously impaired. In such cases, the psychoneurotic symptoms are of such severity and persistence that there is pronounced impairment in the ability to obtain or retain employment. A 100 percent schedular evaluation was warranted when the attitudes of all contacts, except the most intimate, are so adversely affected as to result in virtual isolation in the community; there are totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as phantasy, confusion, panic, and explosions of aggressive energy resulting in a profound retreat from mature behavior; or there is a demonstrable inability to obtain or retain employment. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1987). Effective February 3, 1988, the rating criteria for evaluating PTSD were amended to replace certain adjectives describing the appropriate level of severity to warrant assignment of a particular rating. Specifically, for a 30 percent evaluation, "definite industrial impairment" was substituted for "considerable industrial impairment." For a 50 percent evaluation, "considerably" and "considerable" were substitute for, respectively, "substantially" and "severe." For a 70 percent evaluation, "severely" and "severe" were substituted for, respectively, "seriously" and "pronounced." For a 100 percent evaluation, "fantasy" was substituted for "phantasy." See 38 C.F.R. § 4.132, Diagnostic Code 9411 (1995). The Board notes that each of the three criteria for a 100 percent rating under Diagnostic Code 9411 was an independent basis for granting a 100 percent rating. See Johnson v. Brown, 7 Vet. App. 95 (1994). Effective November 7, 1996, a 30 percent evaluation is warranted for occupational and social impairment with an 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, and recent events). A 50 percent rating is assigned 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 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 for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2007). Generally, in a claim for an increased rating, where the rating criteria are amended during the course of the appeal, the Board considers both the former and the current schedular criteria. Should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); see also VAOPGCPREC 7-2003. After reviewing the evidence of record, the Board concludes that the veteran is entitled to a 50 percent rating for PTSD, effective from July 10, 1984. Turning first to the criteria in effect prior to February 3, 1988, the only contemporaneous medical evidence consists of the report of the July 1984 VA examination documenting complaints including nightmares, apathy, and episodes of rage. Although mental status findings were essentially normal at the time, he apparently received counseling for his symptoms for several years following the examination, and maintains that his symptoms have been present in varying degrees of severity to the present. The Board notes that the more recent medical evidence continues to demonstrate symptoms including nightmares and other sleep disturbances, disturbances of motivation, and rage episodes. In the Board's opinion, given the veteran's history of counseling in the mid to late 1980s and his assertions concerning the presence of psychiatric symptoms since the July 1984 examination, and with consideration of the level of psychiatric disability evidenced by the medical evidence obtained since 1999, the veteran's service-connected PTSD since July 10, 1984 is most accurately characterized as productive of substantial impairment in the ability to establish or maintain effective or favorable relationships with people. The Board notes that the terms "substantially impaired" and "severe industrial impairment" are not synonymous, and finds that the evidence does not show that the psychoneurotic symptoms associated with PTSD also resulted in severe industrial impairment. Nevertheless, given the substantial impairment in the area of interpersonal relationships caused by the PTSD, the Board finds that the overall disability picture associated with the PTSD warrants assignment of a 50 percent evaluation. The Board finds, however, that a disability rating in excess of 50 percent is not warranted. In this regard, the Board notes that although the veteran clearly experiences difficulty in interpersonal relationships, he was able to maintain employment with the same employer from 1984 to 2002, by his own account performing well without any problems until his employer adopted a different approach to tasks in 1999. The veteran reported to examiners that he was never close to his coworkers, but did get along with them without problems. Although at one point he indicated that he did not get along with supervisors and was coerced into retirement, the fact that he was employed for almost two decades by his agency, and that he elected to retire after realizing that he had sufficient Federal service, suggests that any problems he was experiencing with his supervisors were not affecting his ability to remain employed. He indicates that he has documents showing that he would have been fired had he not retired, but he has failed to submit those documents. Moreover, although he relates that he was fired from four jobs after he retired, there is no indication, either in his statements or from the evidence, that the PTSD contributed to his inability to maintain employment. To the contrary, for one of the positions, the veteran explained that he actually lasted longer than most people in that high turnover job. The veteran contends that he has no friends and experiences marital problems. As already noted, he acknowledges that he got along with his coworkers, and has not described any conflicts at work. With respect to his marriage, he has described that particular marriage as turbulent, but also as stable. The record also shows that he has been married to the same person for more than two decades. The veteran describes only sporadic violence between the two, with the most violent action by him involving pushing. The Board finds it noteworthy that by the veteran's own account, his rare physical altercations with his spouse involve mutual assault, and at least sometimes are initiated by his spouse rather than by him. In any event, the record shows that the two have been involved with marital counseling, and as already noted, he considers the marriage stable. He also maintains contact with several of his children. In short, the evidence does not show that his ability to maintain effective or favorable relationships with people is seriously impaired. Nor, does the evidence show, in light of his lengthy work history, that his psychiatric symptoms including nightmares, intrusive recollections, anger problems, flashbacks, hypervigilance, depression, and lack of motivation, are even remotely of such severity and persistence as to result in pronounced impairment in the ability to obtain or maintain employment. In addition, the veteran's admitted capability in getting along with others outside of his family when required is inconsistent with finding that his symptoms have resulted in virtual isolation in the community. Although at his June 2003 VA examination he reported suicidal ideation, he also described such thoughts as fleeting and infrequent. The treatment records themselves consistently show that he denied suicidal ideation. He did report suicidal ideation at his June 2006 examination. Given, however, his consistent denial of such symptoms to his treating clinicians up through 2006, and his description of any such thoughts to the June 2003 examiner as fleeting, the Board finds his complaints of suicidal ideation in June 2006 to lack credibility. Moreover, although the veteran reported one episode of road rage and has engaged in physical altercations with his spouse (which largely, if not exclusively, involved mutual assaults), he has consistently denied homicidal ideation, and he does not contend that there were any legal consequences resulting from his anger outbursts. The Board also notes that the veteran has reported experiencing confusion. He has consistently presented as alert and oriented to VA examination and when evaluated by treating clinicians. There is otherwise no evidence demonstrating the presence of such confusion. In sum, the evidence does not show that the veteran's symptoms have resulted in virtual isolation in the community, or in gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities. Accordingly, the Board finds that the criteria for a 50 percent rating, but not higher are met under the criteria in effect prior to February 3, 1988. Turning to the criteria in effect between February 3, 1988, and November 6, 1996, the veteran's PTSD arguably meets the criteria for a 50 percent evaluation based on the presence of considerable impairment. To warrant a higher evaluation, the evidence must show severe impairment in the ability to establish and maintain effective or favorable relationships with people, and severe industrial impairment resulting from psychoneurotic symptoms. As noted previously, the Board does not find "substantial" to be synonymous with "severe." Moreover, and as already discussed, the Board finds that the veteran's PTSD has not resulted in severe impairment. He was employed on a full time basis from 1984 until 2002. He reports experiencing problems at work beginning in 1999, but in response to the manner in which his agency changed its approach, rather than due to his PTSD. He contends that he was coerced into retirement, but acknowledges that his decision to retire was based on his eligibility after 34 years of Federal service. He has not adduced any evidence supportive of his contention that he would have been fired had he not retired. He contends that he was fired from four subsequent jobs, but has not described the basis for his termination or otherwise explained the involvement of his PTSD. Although the treatment records at one point note that he was experiencing severe relationship difficulties on account of his PTSD, the relationship in question pertained to his marriage, and not his job. He in fact reports having had cordial relationships with his former coworkers. Moreover, even with respect to the marriage, the veteran and his spouse have been involved in counseling for a number of years, and the veteran himself describes the marriage as stable. He maintains contact with several of his children. In addition, his PTSD symptoms have consistently been described by his examiners as moderate in nature. The December 1999 examiner noted that psychological testing revealed that the veteran was able to function in all areas. The June 2003 examiner described the psychiatric impairment as only mild to moderate in nature. The June 2006 examiner concluded that the veteran's PTSD was productive of moderate difficulty. His mental status findings have been consistent with no more than a moderate degree of disability, with disturbances of mood and affect the only abnormalities. Again, while the veteran reports rare altercations with his spouse, he also describes the encounters as mutual assaults. He described an episode of road rage, but did not describe any ensuing violence or legal consequences. At his June 2003 examination he reported fleeting suicidal thoughts, and occasional violent thoughts, and the June 2006 examiners described the veteran's impulse control as poor. Notably, however, his VA treatment records do not corroborate his account of suicidal or violent thoughts, and his judgment in any event was consistently described as good. In sum, the evidence does not demonstrate that the PTSD is productive of severe impairment in the ability to establish and maintain effective or favorable relationships, or severe impairment in the ability to obtain or retain employment. Nor does the evidence show that the veteran's symptoms have resulted in virtual isolation in the community, or in gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities. A rating in excess of 50 percent under the criteria effective February 3, 1988, therefore is not warranted. Turning to the current criteria in effect since November 7, 1996, the Board notes that the veteran's PTSD symptoms are productive of a disability level commensurate with the criteria for a 50 percent evaluation. With respect to a rating higher than 50 percent however, the Board notes that he does not evidence any obssessional rituals, speech abnormalities, near-continuous panic, spatial disorientation, neglect of personal appearance or hygiene, inability to establish and maintain effective relationships, gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, disorientation to time or place, or memory loss. Although the veteran reported to the June 2003 examiner that he experiences suicidal thoughts, the Board again notes that those thoughts were fleeting, and in any event that his account is undermined by years of VA treatment records recording his consistent denials of any such thoughts (even after June 2003). As discussed previously, his June 2006 report of suicidal ideation lacks credibility. Moreover, while he reports altercations with his spouse and the June 2006 examiner described the veteran's impulse control as poor, the Board points out that those altercations, by the veteran's own account, were provoked. He reports one episode of road rage, but did not describe any ensuing physical altercation or legal consequences, and there is otherwise no evidence of impaired impulse control. His judgment is considered good by VA examiners. Moreover, the June 2006 examiner himself described the veteran's psychiatric difficulties as moderate in nature. There is otherwise no evidence suggesting the type of impaired impulse control contemplated by a 70 percent or 100 percent evaluation (i.e. resulting at least in social and occupational impairment with deficiencies in most areas). Although the veteran experiences depression and lack of motivation, the evidence does not show that it is near- continuous in nature, or that it affects his ability to function independently, appropriately, and effectively. The June 2006 examiner did find that the PTSD now compromised the veteran's activities of daily living to an extent, and resulted in difficulty in making decisions, but nevertheless described the impairment as moderate, assigning a GAF score commensurate with that assessment. In fact, the veteran has consistently presented with adequate hygiene. The Board notes that the veteran reports that he began experiencing problems at work, including concentration difficulties, in 1999. Notably, however, there is no indication that his PTSD was responsible for his problems. He also reported that he was able to work around his concentration problems. In short, the record does not show significant difficulty in adapting to stressful circumstances. The affect of the veteran's PTSD on his current employment status has been discussed previously. The veteran retired from his former Federal job, and has not submitted the evidence purportedly demonstrating adverse personnel action taken against him on account of his PTSD. Nor does the evidence otherwise suggest his agency was considering terminating his employment, and the veteran has provided no information or evidence on which to conclude that his PTSD impacted the four jobs from which he was purportedly terminated since 2002. Nor does the record demonstrate substantial or total social impairment. His social skills are considered fair, he retains relationships with some children and with his spouse, and he relates that his relationships with former coworkers were cordial. The Board notes that his VA examiners have described his PTSD symptoms as no more than moderate in nature. The June 2003 examiner assigned a GAF score of 60, and the June 2006 examiner assigned a score of 51. His treating clinicians have not assigned a GAF score lower than 55. GAF scores ranging between 51 and 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). See generally, Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p. 32) (DSM-IV). In short, the evidence on file does not demonstrate symptoms suggesting total occupational and social impairment, or even occupational and social impairment with deficiencies in most areas. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (the psychiatric symptoms listed in the rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings). Accordingly, the Board concludes that an evaluation in excess of 50 percent for PTSD under the criteria in effect since November 7, 1996, is not warranted. In sum, the evidence supports assignment of a 50 percent evaluation for PTSD for the period since July 10, 1984, but the evidence preponderates against assignment of an evaluation in excess of 50 percent under any version of the rating criteria from July 1984 to the present. The Board has considered whether the case should be referred for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1) (2007). The veteran contends that he is unable to work because of his PTSD. The record shows, however, that notwithstanding his perceived pressure to leave employment, he voluntarily retired with at least 34 years of Federal service. He has not submitted evidence showing that his agency was taking adverse action against him on account of any behavior associated with his PTSD. Moreover, although he contends that he lost four subsequent jobs due to his PTSD, he has not provided any information as to how his PTSD impacted those jobs, and instead has suggested that the jobs involved a high turnover rate. The Board points out that his VA examiners have determined that his PTSD is no more than moderate in nature, and his mental status findings are inconsistent with the type of severe interference with employment the veteran reports. The Board consequently finds that the evidence does not support the veteran's assertion of marked interference with employment. In addition, there is no evidence that his psychiatric disability has necessitated frequent periods of hospitalization or that the manifestations of the disability are unusual or exceptional. Therefore, the Board finds that the criteria for submission for an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 237 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996) ; Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board lastly notes that the RO, in granting service connection for PTSD, assigned an effective date for the grant of July 10, 1984. The Board has reviewed the evidence on file and concludes that the underlying level of severity for the veteran's PTSD has remained at the 50 percent level, but no more, since the award of service connection. For the reasons enumerated above, and because there is no indication of greater disability than that described above during the period beginning July 10, 1984, a higher rating is not warranted for any time since the award of service connection. See Fenderson v. West, 12 Vet. App. 119 (1999). ORDER Subject to the controlling regulations applicable to the payment of monetary benefits, a 50 percent disability evaluation for PTSD from July 10, 1984, is granted. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs