Citation Nr: 1014438 Decision Date: 04/15/10 Archive Date: 04/29/10 DOCKET NO. 06-24 951 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to November 25, 2009, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321. 2. Entitlement to a rating in excess of 50 percent for PTSD, since November 25, 2009, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321. REPRESENTATION Appellant represented by: Marine Corps League ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from January 1964 to January 1968. This appeal to the Board of Veterans' Appeals (Board) arose from a July 2005 rating decision in which the RO, in part, granted service connection and assigned an initial 10 percent rating for PTSD, effective March 10, 2004. In the rating decision on appeal, the RO also denied service connection for bilateral hearing loss, tinnitus and hemorrhoids. In September 2005, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in February 2006, and the Veteran filed a substantive appeal in July 2006 as to the issue of a higher rating for PTSD only. In a July 2008 supplemental statement of the case (SSOC), the RO awarded a higher initial rating of 30 percent for PTSD retroactive to the original effective date. Later in July 2008, the Veteran indicated that he wished to continue his appeal. In February 2009, the RO issued another SSOC reflecting the continued denial of an initial rating greater than 30 percent. Because the appeal involves a request for a higher initial rating following the grant of service connection, the Board characterized the claim on appeal in light of Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). In June 2009, the RO remanded the claim on appeal to the RO, via the Appeals Management Center (AMC), for further development. Aside from addressing the Veteran's claim for higher rating for his service connected PTSD, in the remand, the Board also noted that the Veteran had filed a November 2008 NOD in response to a January 2008 rating decision, which denied service connection for erectile dysfunction, and a November 2008 rating decision, which denied entitlement to service connection for sleep apnea. However, as the Veteran had not been furnished an SOC on either issue, the Board instructed the RO to issue an SOC pertaining to both of these issues and to afford the Veteran the appropriate opportunity to file a substantive appeal perfecting an appeal as to these issues. See 38 C.F.R. § 19.29; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); Holland v. Gober, 10 Vet. App. 433, 436 (1997). The Board notes that the Veteran was furnished an SOC in October 2009 pertaining to both service connection claims. However, he did not perfect an appeal of either claim by filing a timely VA Form 9. See 38 C.F.R. §§ 20.202, 20.302(b). After accomplishing the development in relation to the Veteran's claim for higher rating for PTSD, as reflected in a December 2009 SSOC, the RO continued the assigned 30 percent rating for PTSD for the time frame prior to November 25, 2009 and awarded a higher, 50 percent rating, for PTSD effective November 25, 2009, As indicated above, in this appeal, the RO has awarded a higher rating for PTSD from November 25, 2009. However, as higher ratings for this disability are available before and after that date, and the Veteran is presumed to seek the maximum available benefit for a disability, the Board has recharacterized the appeal as encompassing both matters set forth on the title page. Fenderson, 12 Vet. App. at 126; A.B. v. Brown, 6 Vet. App. 35, 38 (1993). The Board has also expanded each claim on appeal to include extra- schedular consideration, consistent with the record and what the RO has actually adjudicated. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim on appeal have been accomplished. 2. Prior to November 25, 2009, the Veteran's psychiatric symptoms primarily included chronic sleep disturbance, nightmares, flashbacks, intrusive thoughts, hypervigilance, exaggerated startle response, anxiety, depressed mood, social isolation, anger, irritability and difficulty forming and maintaining relationships; collectively, these symptoms are indicative of no more than 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). 3. Since November 25, 2009, the Veteran's psychiatric symptoms have primarily included dysphoric mood, constricted affect, lethargy, fatigue, irritability, lack of motivation, sleep impairment, memory impairment and social isolation; collectively, these symptoms are indicative of no more than occupational and social impairment with reduced reliability and productivity. 4. At no point since the March 10, 2004 effective date of the grant of service connection has the Veteran's PTSD been shown to be so exceptional or unusual as to render the schedular criteria inadequate for rating the disability. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for PTSD, prior to November 25, 2009 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, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2009). 2. The criteria for a rating in excess of 50 percent for PTSD, from November 25, 2009, 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, 4.3, 4.7, 4.126, 4.130, DC 9411 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2009)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2009). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353- 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, after the RO's award of service connection and the Veteran's disagreement with the initial rating assigned, the February 2006 SOC set forth the criteria for all higher ratings for PTSD. Subsequently, a November 2009 post-rating letter provided notice as to what information and evidence was needed to support the claim for higher rating, what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The letter also specifically informed the Veteran to submit any evidence in his possession pertinent to the claim on appeal (consistent with Pelegrini and the version of 38 C.F.R. § 3.159 then in effect). Additionally, the letter provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. After issuance of the above-described notice, the December 2009 supplemental SOC (SSOC) reflects readjudication of the claim for higher rating. Hence, the Veteran is not shown to be prejudiced by the timing of the latter notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. Pertinent medical evidence associated with the claims file consists of the Veteran's VA outpatient treatment records and the reports of September 2007 and November 2009 VA examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran and by his representative, on his behalf. No further RO action on this matter, prior to appellate consideration, is warranted. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter on appeal, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2009). When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7 (2009). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a Veteran. 38 C.F.R. § 4.3 (2009). A 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 entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. Here, as the RO has already assigned staged ratings for the Veteran's PTSD, the Board will consider the propriety of those ratings, to include whether any further staged rating of the disability is warranted. The ratings for the Veteran's PTSD have been assigned pursuant to DC 9411. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, 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 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 rating is assigned 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. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). At the outset, the Board notes that, in addition to PTSD, the medical evidence below also reflects a diagnosis of major depressive disorder. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service- connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service- connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). As there is no indication here it is possible to distinguish the symptoms from the Veteran's various psychiatric disorders, the Board has considered all of his psychiatric symptoms in evaluating his service- connected PTSD. A. Prior to November 25, 2009 Social Security Administration (SSA) records reflect that the Veteran reported that he took early retirement from his job as an ironworker in May 2002 due primarily to knee disability and PTSD. He also reported that he did some work after he retired and that the last job he worked on was in the summer of 2004. He noted that he would have continued to work in the summer were it not for his disabilities. The report of a May 2004 VA psychological evaluation reflects that the Veteran's presenting problems were feelings of irritability, impatience and frustration. He also was experiencing increased feeling of distress when viewing news of the Iraq war. It was noted that the Veteran drove himself to all scheduled appointments and was always appropriately groomed. He was friendly and willing to establish a rapport with the interviewer as evidenced by his ability to engage in spontaneous conversation. He presented with a cooperative attitude and an appropriate affect. He maintained good eye contact and a relaxed posture and spoke clearly with an appropriate rate and volume. His speech and thought processes were coherent and he exhibited no visible anxiety. He denied any suicidal or homicidal ideation and his self- perception, orientation, memory, judgment and insight were all intact. The evaluating psychologist noted that the Veteran's PTSD symptoms included recurrent and distressing recollections of traumatic experiences, recurrent nightmares about traumatic experiences, physical alarm to reminders of trauma, efforts to avoid reminders of his war experiences, outbursts of rage, problems with memory, persistent feeling of imminent danger requiring constant vigilance, feeling jumpy or easily startled, a lack of trust in others, difficulties forming intimate relationships, numbness of feelings, difficulties with concentration, inability to enjoy previously enjoyable activities, occasional disrupted sleep and night sweats, and efforts to avoid thinking about and talking about his stressful military experiences. Results of psychological testing were consistent with a diagnosis of PTSD and dysthymic disorder, and indicated mild to moderate levels of distress. The psychologist noted that the Veteran would lose patience quickly and became frustrated easily. In recent years he had also found it more challenging to avoid intrusive thoughts regarding his military experience. Communicating thoughts and feelings was also difficult for him, which hindered the development and maintenance of intimate relationships. The psychologist indicated that the Veteran had demonstrated significant resilience in managing his intense distress by gaining control of his alcohol consumption and finding employment that would not exacerbate his condition. VA outpatient treatment records from February 2004 to October 2009 reflect ongoing treatment for PTSD, including group and individual therapy and medication management. GAF scores ranged from 61 (assigned during the May 2004 psychological evaluation) down to 50 (noted in a July 2006 progress note). In a September 2005 letter accompanying the Veteran's NOD, the Veteran's spouse reported that the Veteran experienced ongoing nightmares. She also indicated that he had an exaggerated startle response; if she or another family member woke him up by touching him, he would jump up and be ready to hit whoever was there. Additionally, the spouse reported that the Veteran suffered from moodiness, constant twitching of the legs and feet while sleeping, and anger problems, which sometimes resulted in him hitting the walls. A September 2005 VA progress note reflects that the Veteran reported an increase in anxiety attacks since receiving a negative response from the RO concerning his PTSD claim. He felt injured by the results and was experiencing an intense feeling of betrayal. In a July 2006 statement accompanying his Form 9, the Veteran indicated that he had never felt safe in social situations since his return from Vietnam. He had also had difficulty sleeping since his tour in Vietnam, with severe leg twitching, night sweats and recurring nightmares. Additionally, he reported suffering from survivor guilt, irritability, anger management problems and exaggerated startle response, to the point where he would "hit the deck" if he heard a car backfiring. Further, he noted that he had had to give up hunting due to it reminding him of the trauma he experienced in Vietnam. A July 2006 VA group counseling note reflects that a GAF score of 50 was assigned. On October 2006 private psychological evaluation, the Veteran reported difficulty falling asleep with nightmares and nighttime waking. He also reported flashbacks, hypervigilance, exaggerated startle response, a loss of appetite without weight loss, ongoing depression, feelings of hopelessness, irritability, restlessness, fatigue, diminished self-esteem, concentration difficulties, diminished sense of pleasure and social withdrawal. Additionally, he reported some suicidal ideation without a plan or intent. He indicated that he would get anxious quite a bit and would occasionally experience heart palpitations. He did not report experiencing panic attacks, however. The Veteran indicated that he did not socialize with friends and did not get along well with his family. He noted that his hobbies included golf and fishing and he spent his days trying to keep busy and helping his daughter with babysitting and house repairs. Mental status examination revealed that the Veteran's speech was fluent and clear, his affect was appropriate and of full range, his insight and judgment were good and his thought processes were coherent and goal-directed. His mood was deemed to be dysthymic and attention and concentration were found to be intact. Recent and remote memory skills were noted to be mildly impaired. With regard to vocational functioning, the psychologist commented that the Veteran was able to follow and understand simple directions and instructions and was able to perform simple tasks independently. It was noted that he might have some difficulty maintaining attention and concentration but was able to maintain a regular schedule, learn new tasks, perform complex tasks independently and to make appropriate decisions. The psychologist indicated that the Veteran might have some difficulty relating adequately to others and appropriately dealing with stress. The diagnoses were dysthymic disorder and PTSD. On September 2007 VA psychiatric examination, the Veteran reported that he had not worked at all since retiring six years prior. The examiner commented that it appeared that the Veteran suffered from moderate occupational impairment, noting that it would be expected that his PTSD symptoms, including being short-tempered, intolerant and abrasive, may have played a role in work difficulties and his decision not to continue working. In regard to social impairment, the Veteran reported that he did not have any friends and only associated with his family. However, further inquiry by the examiner revealed that the Veteran did belong to the Elks Club and a golf league, in which he participated sometimes. The Veteran stated that he drank about 5 beers per day. Mental status examination revealed that the Veteran's speech was logical and focused at all times. He described his typical mood as dysphoric. He stated that when he was working he had a short temper and used to scream at employees and punch walls. He denied symptoms of serious mental illness, such as auditory or visual hallucinations or paranoia. He also denied brooding or compulsions. He reported that in the past he had had experienced an anxiety attack on one occasion but that he was not having such attacks currently. He also reported low self-esteem and lousy concentration. However, in regard to concentration, the examiner noted that a simple test of short term memory did not reveal any obvious deficits. Additionally, the Veteran reported some feelings of hopelessness and helplessness. He denied ever feeling worthless or ever feeling homicidal or suicidal. He noted that both he and his wife managed their finances and the examiner found that the Veteran was competent to manage his own funds. The Veteran reported that he thought about in-service stressors every night. He typically would think about them before he went to bed. He indicated that he had had nightmares in the past about both real and imagined in- service events. He also stated that he had had flashbacks on a couple of occasions. When asked about hobbies, the Veteran reported that he liked boating and fishing and enjoyed playing golf. The examiner commented that the Veteran was moderately impaired in his overall functioning with a history of chronic sleep disturbance, and episodes of agitation and irritability. The examiner found that the Veteran was moderately impaired in his occupational functioning as well. The Veteran had taken early retirement no doubt in part related to being short-tempered and irritable. He was also noted to display mild impairment in social functioning. A GAF score of 60 was assigned. An April 2008 progress note written by a VA psychologist specifically reported on the status of the Veteran's PTSD symptomatology. The note indicated that the Veteran's symptoms remained chronic and persistent and continued to prevent him from conducting normal daily activities of relationships and work. His salient problems continued to be sleep disturbance, persistent irritability, occasional rage outbursts, severe mistrust of others, social isolation, disassociation, memory and concentration problems, and reexperiencing of traumatic memories. A GAF score of 54 was assigned. In a July 2008 statement, the Veteran indicated that he had major depression and anxiety. He could not sleep for more than three hours at a time and he had major nightmares that included recurrences of what transpired in Vietnam. He also indicated that he had flattened affect and he could not control his body's reaction when fireworks were set off; his knees would just give out. He had no motivation the majority of the time, which also made him short tempered and moody. Additionally, he reported that he experienced 5 to 10 panic attacks per week and that he had no social relationships. A July 2008 VA behavioral health progress note reflects that the Veteran was basically stable, that his medications were renewed and that he did not require any new medications. The Veteran was noted to be pleasant and cooperative. A subsequent August 2008 VA home health note reflects that the Veteran received a call from a VA nurse to check on his status. The Veteran reported that he was taking his medication as prescribed and he denied any problems. The nurse described the Veteran's demeanor as calm and cooperative. The Board finds that the above-cited evidence, as a whole, demonstrates that prior to November 25, 2009, the Veteran's service-connected PTSD was no more than 30 percent disabling. The competent medical evidence collectively reflects that during this time frame, the Veteran's psychiatric symptoms included primarily, chronic sleep disturbance, nightmares, flashbacks, intrusive thoughts, hypervigilance, exaggerated startle response, anxiety, depressed mood, social isolation, anger, irritability, and difficulty forming and maintaining relationships. Overall, the Board finds that these symptoms more nearly approximate 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), the level of impairment contemplated in the currently assigned 30 percent disability rating for the period prior to November 25, 2009. At no point prior to November 25, 2009 did the symptoms meet the criteria for a rating in excess of 30 percent. In this regard, the evidence of record did not objectively show that the Veteran had 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 to the point where he could only retain highly learned material and would forget to complete tasks; impaired judgment; or impaired abstract thinking. Rather, the Veteran's speech, thinking and judgment were described as coherent, logical and intact. Also, although the May 2004 psychological evaluation report includes a notation that the Veteran had "problems with memory", the examiner found that the Veteran's memory was intact. Additionally, the October 2006 private psychologist noted only mild memory impairment and the September 2007 VA psychiatric examiner found that there were no obvious deficits in short term memory. There is no other objective evidence of record prior to November 25, 2009 indicating memory impairment to the point of only retaining highly retained material or forgetting to complete tasks. Similarly, although the Veteran reported in July 2008 that he was experiencing five to ten panic attacks per week along with a flattened affect and earlier reported in September 2005 an increase in "anxiety attacks," there is no objective evidence of record, that prior to November 25, 2009, he had panic attacks more than once a week or a flattened affect. None of the reports of mental health evaluations of record note any flattened affect or panic attacks, with both the October 2006 private psychologist and the September 2007 VA psychiatrist specifically noting that the Veteran had reported that he had not had any panic attacks. Also, the April 2008 VA progress note's list of current symptoms did not include panic attacks or flattened affect. Additionally, the July and August 2008 VA progress notes, contemporaneous to the Veteran's report of panic attacks and flattened affect, also did not note either of these symptoms and generally found that the Veteran's PTSD was stable and that he did not require any additional medications. The Board presumes that had the Veteran actually been experiencing his asserted level of distress in July 2008, he would have reported it to his treating mental health professionals (in addition to reporting it to the RO). Accordingly, in the absence of any objective documentation, of panic attacks more than once a week or flattened affect prior to November 25, 2009, the Board does not find the Veteran's July 2008 report of this symptomatology credible. The Board notes that, prior to November 25, 2009, the record does tend to indicate that the Veteran had some level of disturbances of motivation and mood, and that he was deemed to have some difficulty in establishing and maintaining effective work and social relationships. He also reported suicidal ideation on one occasion during the October 2006 private psychological evaluation. However, although the Veteran initially reported to the September 2007 VA examiner that he did not have any friends and only associated with his family, he later indicated that he did belong to the Elks Club and did participate in a golf league. Also, while the Veteran clearly did have some difficulty with relationships at work prior to his retirement, the evidence does not establish that this difficulty prevented him from adequately performing his job duties. In addition, the October 2006 report of suicidal ideation was very much an isolated report. During the subsequent September 2007 VA examination, the Veteran denied that he had ever felt suicidal and there is no other evidence of record indicating that the Veteran had any ongoing problem with suicidal ideation prior to November 25, 2009. Accordingly, the Board finds that, although the Veteran did have some mood and motivation disturbance and experienced some difficulty with work and social relationships, in the absence of other PTSD symptoms compatible with the assignment of a higher, 50 percent rating, and in the presence of specific functional indicators compatible with the assignment of a 30 percent rating (i.e. generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), the assignment of the higher 50 percent rating is not warranted prior to November 25, 2009. The Board is cognizant that the April 2008 VA progress note includes a notation from a VA psychologist that the Veteran's PTSD symptoms "prevented" him from conducting the normal daily activities of relationships and work. Such a notation tends to indicate more severe impairment than that contemplated in the assigned 30 percent rating. However, the Board also notes that the May 2004 VA psychologist affirmatively found that the Veteran had been able to find employment that would not exacerbate his PTSD; the October 2006 private psychologist simply found that the Veteran might have difficulty relating adequately to others and appropriately dealing with stress in the work setting, and the September 2007 VA psychiatrist simply found that the Veteran's PTSD may have played a role in his work difficulties and decision not to continue working. Consequently, as the September 2007 examiner, in particular, was specifically charged with evaluating the level of the Veteran's occupational and social impairment for rating purposes (and as there is no indication that that the Veteran's level of functioning declined between September 2007 and April 2008), the Board attaches significantly more weight to his assessment than to the brief notation presented by the VA psychologist in April 2008. Additionally, the Board notes that although the VA psychologist expressed that the Veteran's symptoms "prevented" him from conducting daily activities of work, he assigned the Veteran a GAF score of 54, which is generally indicative of moderate symptoms, including moderate difficulty in social, occupational or school functioning, as opposed to total impairment of such functioning. The Board also points out that none of the GAF scores assigned between March 10, 2004 and November 25, 2009 provides a basis for assignment of any higher rating for the Veteran's PTSD. Predominantly, the assigned GAF scores ranged from 51 to 61, with a single isolated score of 50 assigned in July 2006. According to the DSM-IV, GAF scores ranging 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, unable to keep a job). GAF scores ranging between 51 and 60 are indicative of moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 61 and 70 are indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. The assigned GAF of 61, indicating mild overall impairment, clearly suggest even less impairment than contemplated in the assigned 30 percent rating, whereas the GAFs from 51 to 60 generally suggest an overall moderate degree of impairment, consistent with the 30 percent rating assigned. While the GAF score of 50 assigned in July 2006 is, conceivably, suggestive of a level of impairment greater than that contemplated in the 30 percent rating, the Veteran was not shown to manifest any of the symptoms delineated in the DSM- IV-such as suicidal ideation, severe obsessional rituals, or frequent shoplifting. Moreover, as discussed above, the Veteran's underlying symptoms do not support the assignment of at least the next higher, 50 percent rating, or any even higher rating, under VA's rating schedule. Hence, a higher rating is not assignable on the basis of the GAF of 50, alone. As indicated above, the Board emphasizes that a veteran's symptoms, and not an assigned GAF score, provide the provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). For the above-stated reasons, the Board finds that the Veteran's psychiatric disability picture has, prior to November 25, 2009, more nearly approximated the criteria for the 30 percent rather than the 50 percent rating. See 38 C.F.R. § 4.7. As the criteria for the next higher, 50 percent, rating are not met, it logically follows that the criteria for the higher ratings of 70 percent and 100 percent are likewise not met. B. Since November 25, 2009 On the November 25, 2009 VA psychiatric examination, the Veteran reported that he often felt depressed, low and down; that he generally did not feel like getting out of bed; and that he would mostly stay at home. Mental status examination revealed that he appeared lethargic and fatigued, with a constricted affect and a dysphoric mood. He was able to do serial 7s and spell a word forward and backward. He was oriented to person, time and place and had sufficient judgment to understand the outcomes of his behavior. Additionally, he had enough insight to understand that he had a psychiatric problem. Regarding sleep impairment, the Veteran reported that he would often wake up from sleep and would feel irritable and tired the next day. He also reported experiencing panic attacks once every few days to a week and that he tended to have four to five attacks on these days. He would isolate himself while experiencing these attacks. The examiner noted that the Veteran did not have any homicidal or suicidal thoughts. The extent of his impulse control was deemed to be good. The effect of the Veteran's PTSD on his mood was that he lacked motivation to go out and socialize with people. He was found to be able to maintain minimum personal hygiene and not to have any problems with his activities of daily living. The examiner commented that the Veteran looked tired and lethargic. His remote memory was moderately impaired, his recent memory was normal and his immediate memory was normal. An example of his memory disorder was that he could not recall the details of his in- service experiences. The examiner diagnosed the Veteran with major depressive disorder and moderate, chronic PTSD. A GAF score of 50 was assigned. The examiner noted that objective evidence on testing of remote memory indicated moderate memory impairment resulting in mild functional impairment. His immediate recent memory, attention, concentration and executive functions were all found to be normal. The Veteran's subjective memory symptoms were not deemed to interfere with his daily functioning. The examiner commented that the Veteran often felt depressed and did not feel like going out, did not socialize with people and isolated himself. He lacked motivation to go out and look for a job. His occupational and psychosocial functional status was impaired from his PTSD and depressive disorder. The Board finds that the evidence, as a whole, demonstrates that since November 25, 2009, the Veteran's service-connected PTSD has been no more than 50 percent disabling. The competent medical evidence collectively reflects that, since November 25, 2009, the Veteran's psychiatric symptoms have included dysphoric mood, constricted affect, lethargy, fatigue, irritability, lack of motivation, sleep impairment, memory impairment and social isolation. Overall, the Board finds that these symptoms more nearly approximate occupational and social impairment with reduced reliability and productivity due to the aforementioned symptoms, a level of impairment contemplated in the currently assigned 50 percent disability rating. However, at no point since November 25, 2009 has the Veteran's psychiatric symptomatology met the criteria for a rating in excess of 50 percent. Notably, the Veteran had not been found to have the underlying level of symptomatology compatible with a higher, 70 percent rating. He has not exhibited suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; 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; or neglect of personal appearance and hygiene. Also although the Veteran has had significant difficulty with social functioning, it is not shown that he is entirely unable to establish and maintain effective relationships. Notably, he still maintains relationships with his family. Additionally, although the Veteran would appear to have difficulty in adapting to stressful circumstances, as the rest of his PTSD symptomatology is not shown to be compatible with the applicable criteria, assignment of a higher, 70 percent rating is not warranted. The Board has also considered whether the GAF score of 50, assigned by the November 25, 2009 examiner, might form the basis for the assignment of a higher rating. Once again, a GAF score ranging from 41 to 50 reflects 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 score of 50 is on the very high end of this scale, however, reflecting more moderate impairment. Accordingly, in the absence of more underlying symptomatology, which could be considered compatible with a higher, 70 percent rating, the assigned GAF score does not provide a basis for assigning such a higher rating. See 38 C.F.R. § 4.126(a). For the above-stated reasons, the Board finds that the Veteran's psychiatric disability picture has, since November 25, 2009, has more nearly approximated the criteria for the 50 percent rather than the 70 percent rating. See 38 C.F.R. § 4.7. As the criteria for the next higher, 70 percent, rating are not met, it logically follows that the criteria for a higher rating of 100 percent likewise are not met. C. Both periods The Board notes that in determining that the criteria for a rating in excess of 30 percent for the Veteran's service- connected PTSD, prior to November 25, 2009, are not met, and that the criteria for a rating in excess of 50 percent for PTSD, from November 25, 2009, are not met, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for the psychiatric disability in question. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board also notes that the above determinations are based on application of pertinent provisions of VA's rating schedule. However, the Board further finds that, at no point since the March 10, 1994 effective date of the grant of service connection has the Veteran's PTSD been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321 (cited to in the December 2009 SSOC). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that schedular criteria are adequate to rate the disability under consideration at each stage. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is 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 additional staged rating of the Veteran's PTSD, pursuant to Fenderson (cited above), and that the claims for higher ratings must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher rating, that doctrine is not for application. See 38 U.S.C.A. §§ 5107(b); 38 C.F.R. § 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53- 56 (1990). ORDER An initial rating in excess of 30 percent for PTSD, prior to November 25, 2009, is denied. A rating in excess of 50 percent for PTSD, from November 25, 2009, is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs