Citation Nr: 1120797 Decision Date: 05/27/11 Archive Date: 06/06/11 DOCKET NO. 99-16 095 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to October 8, 2009. 2. Entitlement to a rating in excess of 50 percent for PTSD, from October 8, 2009 to May 28, 2010. 3. Entitlement to a rating in excess of 70 percent for PTSD, from May 28, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from February 1966 to February 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 1998 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia, in which the RO, in pertinent part, continued a 30 percent rating for PTSD. The Board denied the claim for entitlement to a rating in excess of 30 percent for PTSD in a September 2002 decision. After appeals to the United States Court of Appeals for Veterans Claims (Court) and the United States Court of Appeals for the Federal Circuit (Federal Circuit), the claim for an increased rating was returned to the Board. In January 2009, the Board remanded the claim for a rating in excess of 30 percent for PTSD for further development. In a November 2009 rating decision, the Appeals Management Center (AMC) granted an increased, 50 percent, rating for PTSD, effective October 8, 2009. In February 2010, the Board remanded the claims for increased ratings for PTSD, prior to and since October 8, 2009, for further development. In a February 2011 rating decision, the AMC granted an increased, 70 percent, rating for PTSD, effective May 28, 2010. Despite the increased ratings established for PTSD, the Veteran has not been awarded the highest possible rating. As a result, he is presumed to be seeking the maximum possible benefit and his claims remain in appellate status. A.B. v. Brown, 6 Vet. App. 35 (1993). In the February 2010 remand, the Board highlighted that, in August 2000, the Veteran's former attorney filed a claim for an increased schedular rating for each of his service-connected disabilities, asserting that each had become more severe. At the time of the August 2000 claim, service connection was in effect for PTSD, migraine headaches, residuals of a shell fragment wound of the left buttock, residuals of a shell fragment wound of the left thigh, residuals of a shell fragment wound of the left foot, and residuals of a shell fragment wound of the scalp. In a May 2004 rating decision, the RO granted increased ratings for migraine headaches and residuals of a shell fragment wound of the left thigh. However, as the claims for increased ratings for residuals of shell fragment wounds of the left buttock, left foot, and scalp had not been adjudicated, they were referred to the RO for appropriate action. The claims file does not reflect that any subsequent action has been taken on these claims. The claims for increased ratings for residuals of shell fragment wounds of the left buttock, left foot, and scalp have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over these matters, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claims on appeal has been accomplished. 2. Prior to October 8, 2009, PTSD was manifested by problems sleeping, nightmares, depression, difficulty forming relationships, mood swings, anxiety, flashbacks, intrusive thoughts, panic attacks, and suspiciousness; 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. 3. From October 8, 2009 to May 28, 2010, PTSD was manifested by irritability, sleep disturbance, flashbacks, nightmares, hypervigilance, and avoidant behavior, which affected the Veteran's mood and family relations; these symptoms are indicative of no more than occupational and social impairment with reduced reliability and productivity. 4. Since May 28, 2010, PTSD has been manifested by anxiety, nervousness, flashbacks, panic attacks, depression, nightmares, sleep disturbances, and limited social interactions, with moderate to severe effects on employability; these symptoms are indicative of no more than occupational and social impairment with deficiencies in most areas; total occupational and social impairment is not demonstrated. CONCLUSIONS OF LAW 1. For the period prior to October 8, 2009, the criteria for a rating in excess of 30 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2010). 2. For the period prior from October 8, 2009 to May 28, 2010, the criteria for a rating in excess of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2010). 3. For the period since May 28, 2010, the criteria for a rating in excess of 70 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Court have been fulfilled. In this case, the Veteran's claim for an increased rating was received in July 1998 (when he filed his claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU)). Thereafter, he was notified of the general provisions of the VCAA by the AMC in correspondence dated in February 2009. This letter notified the Veteran of VA's responsibilities in obtaining information to assist him in completing his claims, identified the Veteran's duties in obtaining information and evidence to substantiate his claims, and provided other pertinent information regarding the VCAA. Thereafter, the claims were reviewed and a supplemental statement of the case (SSOC) was issued in February 2011. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). The Court, in Dingess v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was provided in February 2009. The Veteran has been made aware of the information and evidence necessary to substantiate his claims and has been provided opportunities to submit such evidence. A review of the claims file shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claims during the course of this appeal. His VA treatment records have been obtained and associated with his claims file. The Veteran was also provided with VA examinations to assess the current nature of his PTSD in June 1997, September 1998, April 2001, October 2009, and May 2010. The Board notes that, in February 2010, the claims were remanded, in part, to obtain outstanding Social Security Administration (SSA) records. The AMC subsequently requested these records; however, in a March 2010 response, the SSA indicated that the requested medical records could not be sent because the records did not exist and further efforts to obtain them would be futile. Specifically, the SSA indicated that, after exhaustive and comprehensive searches, they were unable to locate the medical records, and further efforts would be futile. Accordingly, the Board finds that further action in regard to obtaining these records is not warranted. See 38 C.F.R. § 3.159(c)(2). The Board has considered the fact that, during the May 2010 VA examination, the Veteran reported that, after returning from Vietnam, he had been in counseling in the Vet Center off and on, although he was not presently going to the Vet Center, and had not been to the Vet Center or the VA Mental Health Clinic in the last three to four years. He also stated that he was being followed by his primary care physician, Dr. R., who was prescribing medication to help with anxiety and sleep. Records of treatment from the Vet Center and Dr. R. have not been associated with the claims file; however, the Board highlights that VA is only obligated to obtain records that are adequately identified and for which necessary releases have been received. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In correspondence dated in March 2001, the RO asked the Veteran to complete and return a separate VA Form VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for any private doctor or hospital that had provided treatment for his disabilities, other than VA Medical Centers (VAMCs). In June 2001, the Veteran returned a VA Form 21-4142 in which he stated that the only doctors he had seen were VA doctors, and the RO should have the pertinent information. In the February 2009 VCAA letter, the AMC asked the Veteran to submit any medical reports regarding treatment for PTSD since November 2000, and asked that he return an enclosed VA Form 21-4142 if he wanted VA to obtain records on his behalf. The Veteran did not subsequently submit any releases; rather, in February 2009, he indicated that he had no other information or evidence to give VA to support his claim, and asked that his claim be decided as soon as possible. In the February 2010 remand, the Board also noted that, during an October 2009 VA examination, the physician noted that the Veteran had been under treatment via the Mental Health Clinic before, but, in the last couple of years, he had been going to his private physician. The Board instructed that the AMC/RO should contact the Veteran and obtain the names and addresses of all medical care providers, VA and non-VA, who treated the Veteran for PTSD since February 2004. In correspondence dated in March 2010, the AMC asked the Veteran to provide the names, addresses, phone numbers (if known) and dates of treatment of any VA and non-VA healthcare providers, to specifically include records of treatment for PTSD since February 2004. He was advised to complete and return an enclosed VA Form 21-4142 for each health care provider. Despite the foregoing letters to the Veteran, he has not submitted a release to obtain Vet Center treatment records or records of treatment from his private primary care physician. Notably, the Court has held that VA's duty to assist is not always a one-way street, and that, if a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); see Swann v. Brown, 5 Vet. App. 229, 233 (1993). Accordingly, in the absence of submission of releases to allow VA to obtain any outstanding treatment records, the Board finds that further action in regard to the aforementioned records is not warranted. Moreover, in light of the VA treatment records currently associated with the claims file, and the five VA examinations conducted during the time period pertinent to the claims on appeal, the Board finds that there is sufficient medical evidence of record to make a decision on the claims on appeal. Furthermore, the Veteran has not identified any additional, relevant evidence that has not been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claims, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claims. Law and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on 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 ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Here, the AMC/RO has already staged the ratings for the Veteran's PTSD; the following analysis is therefore undertaken with consideration of the possibility of further staged rating. General Rating Formula for Mental Disorders: Rating 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 100 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 70 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 50 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) 30 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010) In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). Global Assessment of Functioning (GAF) Scale Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. 80 ? ? 71 If symptoms are present, they are transient and expectable reactions to psycho-social stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 70 ? ? 61 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 relationships. 60 ? ? 51 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). 50 ?? 41 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). The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Factual Background and Analysis Historically, in a July 1997 rating decision, the RO granted service connection and assigned an initial 30 percent rating for PTSD. In July 1998, the Veteran filed his current claim for an increased rating. In the September 1998 rating decision, the RO continued the 30 percent rating for PTSD, pursuant to Diagnostic Code 9411. 38 C.F.R. § 4.130, Diagnostic Code 9411. In the November 2009 rating decision, the AMC granted an increased, 50 percent, rating, effective October 8, 2009. In the February 2011 rating decision, the RO granted an increased, 70 percent, rating, effective May 28, 2010. The Veteran was afforded a VA examination to evaluate his claimed PTSD in June 1997. He described problems sleeping, recurrent nightmares, depression, difficulty forming relationships and trusting people, and mood swings, although he reported that he controlled his temper pretty well. He stated that he had been married to his wife for 28 years, and denied problems in the marriage. On examination, the Veteran was oriented with no evidence of active hallucinations or delusions. He was rather anxious, although pleasant and cooperative. Attention and concentration were impaired. Memory and recall for recent events were slightly impaired. There was no evidence of looseness of associations, flight of ideas, or pressured speech. There were no obsessive thoughts or compulsive actions, and he denied being actively suicidal or homicidal. The Axis I diagnosis was PTSD and a GAF score of 60-65 was assigned. The examiner described the severity of the Veteran's PTSD as moderate, and commented that he was mildly to moderately affected industrially and socially. During VA treatment in September 1997, the Veteran described nightmares, flashbacks, nervousness, restlessness, and sleep disturbance. He denied hallucinations, delusional thinking, and suicidal ideas. The assessment was PTSD. SSA records associated with the claims file reflect that the Veteran was awarded Social Security disability benefits in May 1998, in part, due to PTSD. A May 1998 OHA Psychiatric Technique Review Form indicates that the Veteran experienced generalized persistent anxiety, recurrent obsessions or compulsions which were a source of marked distress, and recurrent and intrusive recollections of a traumatic experience which were a source of marked distress. This form indicates that the Veteran had slight restrictions of activities of daily living, moderate difficulties in maintaining social functioning, only seldom had deficiencies of concentration, persistence, or pace resulting in failure to complete tasks in a timely manner, and never had episodes of deterioration or decompensation in work or work-like settings which caused him to withdraw from that situation or to experience exacerbation of signs and symptoms. During VA treatment in July 1998, the Veteran stated that he got along well with his family, and visited his children in North Carolina, sometimes staying for a month or two in the winter. On examination, speech was spontaneous, relevant, and goal-directed. Mood was euthymic. Affect was appropriate. There was no evidence of hallucinations, delusional thinking, or suicidal or assaultive ideas. The assessment was PTSD and a GAF score of 75 was assigned. The Veteran's PTSD was again evaluated on VA examination in September 1998. He denied any problems in his marriage other than not wanting to be around people and feeling easily irritated and depressed. In discussing his daily activities, the Veteran reported that he tried to walk and visited with his grandchildren. He added that he tried to stay away from crowds and led a very isolated life. He described recurrent nightmares three to four times a month, nervousness, recurrent flashbacks, episodes of depression, and panic episodes once or twice a month. He stated that he got rather suspicious and distrustful, but denied any active hallucinations or delusions. He also denied any suicidal or homicidal ideations or plans. On examination, the Veteran was well-oriented with no evidence of any active hallucinations or delusions. Attention and concentration were impaired and memory and recall for recent events were slightly impaired. Judgment was intact and there was no evidence of any looseness of associations, flight of ideations, pressured speech, obsessive thoughts, or compulsive actions. The Axis I diagnosis was PTSD and a GAF score of 65 was assigned. The examiner again described the Veteran's PTSD as moderate, and stated that he was about the same as when evaluated in June 1997. He added that the extent of the Veteran's problems were mild to moderate and affected him socially and industrially, occasionally. He opined that the Veteran met the criteria for a 30 percent rating, including recurrent flashbacks, panic attacks, and nightmares. The Veteran received VA treatment for PTSD in January, July, and September 1999. These treatment records reflect complaints regarding nightmares and depression. On these dates, the Veteran's speech was spontaneous, relevant, and goal-directed. Mood was described as mildly anxious and euthymic. There was no evidence of hallucinations, delusional thinking, or suicidal or assaultive ideas. GAF scores ranging from 65 to 75 were assigned. During treatment in November 1999, the Veteran complained of insomnia. On examination, activity and speech were somewhat slowed from normal. Thought content was not psychotic, suicidal, or homicidal. Mood was mildly depressed with a narrow range of affect and anxiety in the moderate range. Memory and orientation were intact. A GAF score of 65 was assigned. In June 2000, the Veteran returned for follow-up for PTSD. His activity and speech were not slowed from normal. Thought content was not psychotic, suicidal, or homicidal. Mood was mildly depressed with normal range of affect and anxiety in the moderate range. Memory and orientation were intact. A GAF score of 65 was assigned. On VA PTSD examination in April 2001, the Veteran reported that he had been married for 30 years, and denied any problems with his marriage. In describing his daily activities, he stated that he walked, went on drives, watched television, and spent time with his grandchildren, but had no specific hobbies or interests. He reported that he did not like being around people or going places. He also described nightmares and panic episodes about every two weeks. He reported recurrent palpitations, smothering feelings, and hyperventilation. He added that he had been going to church, which had caused him not to have much problems with temper or anger control. He denied suicidal or homicidal ideation or plan. While he had intrusive thoughts about Vietnam, there were no hallucinations or delusions. On examination, the Veteran was generally pleasant and cooperative, with appropriate flow and content of conversation. He was well-oriented and there was no evidence of any active hallucinations or delusions. Attention and concentration were normal and there were no problems with mental calculations. Memory and recall for recent events were slightly impaired. Judgment was intact and there was no evidence of any looseness of association, flight of ideas, or pressured speech. There were no obsessive thoughts or compulsive actions. The Axis I diagnosis was PTSD. A GAF score of 60 to 65 was assigned. The examiner commented that the Veteran continued to have problems with PTSD, based on recurrent bad dreams, nightmares, flashbacks, startle response, having problems being around people and feeling closed in. He added that the Veteran seemed to be handling his stressors reasonably well. The examiner commented that the Veteran also had problems with chronic headaches and back, buttock, and leg problems, which seemed to contribute to his anxiety and made his PTSD symptoms more frequent. During VA treatment in October 2004, the Veteran complained of feeling "down" and sad, with little interest in things he used to enjoy. He added that he was not sleeping well and had quit all his medicines because they made him tired. On examination, he was appropriately dressed and groomed, with normal affect. Mood was only slightly dysphoric. He denied any suicidal or homicidal thoughts in at least a year, and stated that it had been several months since he had a nightmare. He did describe himself as avoidant of crowds and anxious in crowds. He agreed to talk to his physician about medications, and to resume taking what was prescribed. The assessment was depression, mild, chronic, and PTSD, in remission. The Veteran's PTSD was evaluated during a VA examination on October 8, 2009. He described problems since coming home from Vietnam, including irritability, sleep disturbance, flashbacks, and nightmares. He added that he was hypervigilant to loud sounds, did not socialize, and disliked crowds. He denied major problems with depression as well as suicidal ideation and attempts. He reported that, while he got irritable at home, his anger problems did not get him in trouble with others. The Veteran stated that he had worked in the coal mines for 28 years after service, but had been unable to work since 1995 secondary to back and right hand injuries. In discussing his employment history, he stated that he got along well with people. He also reported getting along well with his family. In describing his daily activities, the Veteran stated that he spent time with his wife, including going on walks. He reported having a dog, dairy farm, and fish ponds, and added that he liked to garden. He went to church and took care of office finances with the help of his wife. He was able to take care of his activities of daily living. On examination, the Veteran was pleasant and calm, with appropriate behavior. Speech and language were normal. Thought process was coherent and logical. Thought content showed no delusions, audiovisual hallucinations, or suicidal or homicidal thoughts. He rated his mood as a 5 on a scale of 1 to 10. The Veteran was oriented to place, situation, day, month, and year, but was unsure of the date. He reported some problems with memory and forgetting things. Immediate memory was one out of three but recent remote memory was intact. There were some concentration problems. Insight and judgment were intact. The Axis I diagnosis was PTSD. A GAF score of 50 to 55 was assigned. The examiner commented that the Veteran continued to suffer from symptoms of PTSD, including flashbacks, nightmares, hypervigilant behavior, and avoidant behavior. He described these symptoms as moderate to severe, and added that service-connected symptoms of PTSD affected him with some mood and family relations, socially and economically. He stated that the Veteran's service-connected symptoms negatively affected him in regard to physical and sedentary employment on a sustained basis. The Veteran's PTSD was most recently evaluated during VA examination on May 28, 2010, performed by the same psychiatrist who conducted the October 2009 VA examination. The Veteran reported that he continued to have problems with anxiety and nervousness since coming back from Vietnam, and described daily flashbacks. He added that he could not tolerate crowds, but liked to be by himself and stayed home with his wife. He reported panic attacks around crowds, as well as feeling depressed with decreased energy, motivation, and interest in activities. He denied major problems with anger. He described nightmares and difficulty sleeping and reported that loud sounds made him jumpy, anxious, and nervous. He reported that he got along well with his family. In describing his daily activities, the Veteran stated that he spent time at home and stayed away from people, although he did go to church, where he did OK. He added that he walked with his wife and dog, and was able to take care of himself. On examination, the Veteran was pleasant and interactive. Thought processes were coherent. There were no delusions, auditory or visual hallucinations, or active suicidal or homicidal thoughts. The Veteran had mood and anxiety issues. Immediate memory was two out of three and recent and remote memory were intact. Insight and judgment were intact. The Axis I diagnosis was PTSD. A GAF score of 50 was assigned. The examiner commented that the Veteran had limited his social interactions quite a bit, as he limited himself mostly to home and did not have many social activities. He opined that the degree of impairment caused by PTSD was best described as occupational and social impairment with deficiencies in most areas relating to work, school, family relations, judgment, thinking, or mood, due to such symptoms as mood problems, fleeting suicidal ideations, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. The examiner further opined that the Veteran's PTSD moderately to severely affected his employability, as his symptoms continued on a daily basis, especially when he was around people or went outside the house. Prior to October 8, 2009 Collectively, the aforementioned medical evidence reflects that, prior to October 8, 2009, the Veteran's PTSD was manifested by problems sleeping, nightmares, depression, difficulty forming relationships, mood swings, anxiety, flashbacks, intrusive thoughts, panic attacks, and suspiciousness. These symptoms are reflective of occupational and social impairment no greater than what is contemplated in the currently assigned 30 percent disability rating. At no point during the period in question has the Veteran's overall PTSD symptomatology met the criteria for a rating in excess of 30 percent. In this regard, the medical evidence does not show the Veteran to have 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; impaired judgment; impaired abstract thinking; or other symptoms of PTSD that are characteristic of a 50 percent rating. Rather, while the Veteran had a narrow range of affect during VA treatment in November 1999, he had normal range of affect during treatment in June 2000. Affect was again described as normal during VA treatment in October 2004. Speech was described as spontaneous, relevant, and goal-directed during VA treatment in July 1998 and January, July, and September 1999. While speech was somewhat slowed during VA treatment in November 1999, it was not slowed from normal in June 2000. There was also no delusional thinking during VA treatment in January, July, and September 1999 and there were no delusions during VA examination in April 2001. Further, judgment was described as intact during the pertinent period. While the Veteran experienced panic attacks during the period in question, on VA examination in September 1998, he reported that he had panic episodes once or twice a month and in April 2001 he described panic episodes about every two weeks. There is no indication that the Veteran experienced panic attacks more than once a week, and panic attacks weekly or less often are contemplated in the 30 percent rating currently assigned. While memory and recall for recent events was slightly impaired on VA examinations in June 1997, September 1998, and April 2001, there is no evidence of impairment of short and long-term memory prior to October 8, 2009. In any event, mild memory loss, including forgetting recent events, is contemplated in the 30 percent rating currently assigned. In addition, while the May 1998 Psychiatric Review from the SSA indicates that the Veteran experienced recurrent obsessions or compulsions which were a source of marked distress, on VA examinations in September 1998 and April 2001, there was no evidence of obsessive thoughts or compulsive actions. Notably, during the period in question, the Veteran reported getting along well with his family. In addition, the Veteran's PTSD was described as only moderate on VA examinations in June 1997 and September 1998, when the examiner commented that he was only mildly to moderately affected industrially and socially. Further, the GAF scores ranging from 60 to 75, assigned prior to October 8, 2009, indicate only mild, moderate, and transient symptoms. Based on the foregoing, the Board finds that the Veteran is entitled to no more than a 30 percent rating for his PTSD prior to October 8, 2009. As the criteria for the next higher, 50 percent, rating have not been met during this period, it logically follows that the criteria for higher ratings of 70 or 100 percent likewise are not met during this time frame. From October 8, 2009 to May 28, 2010 The aforementioned medical evidence reflects that, during the period from October 8, 2009 to May 28, 2010, the Veteran's PTSD was manifested by irritability, sleep disturbance, flashbacks, nightmares, hypervigilance, and avoidant behavior. These symptoms are reflective of occupational and social impairment no greater than what is contemplated in the currently assigned 50 percent disability rating. At no point during the period in question has the Veteran's overall PTSD symptomatology met the criteria for a rating in excess of 50 percent. In this regard, although there is evidence of impairment in mood (as the Veteran reported irritability and described his mood as 5 on a scale of 1 to 10 on VA examination in October 2009) and family relations (as reflected in the opinion of the October 2009 VA examiner), deficiencies in the areas of judgment, and thinking have not been demonstrated. Indeed, on VA examination in October 2009, thought process was coherent and logical, thought content showed no delusions, and judgment was described as intact. Moreover, on VA examination in October 2009, the Veteran denied suicidal ideation and indicated that he was able to take care of his activities of daily living. On examination, speech was normal and, while he was unsure of the date, the Veteran was oriented to place, situation, day, month, and year. While he has reported irritability, the Veteran also reported that his anger problems did not get him in trouble with others, and the evidence does not otherwise reflect impaired impulse control (such as unprovoked irritability with periods of violence). There is also simply no medical evidence of any obsessional rituals which interfere with daily activities. The Veteran was given a GAF score ranging from 50 to 55 in October 2009. The Board acknowledges that a GAF score of 50 indicates serious symptoms; however, the Veteran's symptoms described during that examination do not correlate to the examples for that score. The Veteran was not suicidal, and he stated that he got along well with his family, spent time with his wife, including going on walks, and went to church. No obsessional rituals were described on examination. GAF scores ranging from 51 to 55 indicate moderate symptoms, and more accurately reflect the Veteran's symptoms as described above. Based on the foregoing, the Board finds that the Veteran is entitled to no more than a 50 percent rating for his PTSD for the period from October 8, 2009 to May 28, 2010. As the criteria for the next higher, 70 percent, rating have not been met during this period, it logically follows that the criteria for higher rating of 100 percent likewise are not met during this time frame. From May 28, 2010 The aforementioned medical evidence reflects that, during the period since May 28, 2010, the Veteran's PTSD has been manifested by anxiety, nervousness, flashbacks, panic attacks, depression, nightmares, sleep disturbances, and limited social interactions; with moderate to severe effects on employability. These symptoms are reflective of occupational and social impairment no greater than what is contemplated in the currently assigned 70 percent disability rating. At no point since May 28, 2010 has the Veteran's overall PTSD symptomatology met the criteria for a 100 percent rating. There is simply no evidence of 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; or memory loss for names of close relatives, own occupation, or own name. Rather, on VA examination in May 2010, the Veteran was pleasant and interactive, with coherent thought processes, and there were no delusions or hallucinations. Immediate memory was two out of three and recent and remote memory were intact. The Veteran reported that he got along well with his family and was able to take care of himself. Moreover, the GAF score of 50 assigned in May 2010, reflecting serious symptoms, is consistent with the 70 percent rating currently assigned. Significantly, the May 2010 VA examiner opined that the degree of impairment caused by PTSD was best described as occupational and social impairment with deficiencies in most areas relating to work, school, family relations, judgment, thinking, or mood. He further opined that the Veteran's PTSD moderately to severely affected his employability (as opposed to resulting in total impairment). Based on the foregoing, the Board finds that the Veteran is entitled to no more than a 70 percent rating for his PTSD from May 28, 2010. All Periods During all times at issue, we acknowledge that the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he observed and is within the realm of his personal knowledge; but he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet.App. 465, 469-70 (1994) However, in evaluating the medical assessments given by VA examiners, we find them to be adequate as they are based upon consideration of the Veteran's prior medical history and examinations. Stefl v. Nicholson, 21 Vet.App. 120, 123 (2007); Ardison v. Brown, 6 Vet.App. 405, 407 (1994). In addition, the VA PTSD opinions cited above support their conclusions with analysis. Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007). "Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions [without reasoning or rationale]." Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 304 (2008). Finally, the opinions generally support the same findings and are consistent. Thus, the Board finds these opinions to be reliable assessments of the degree of impairment caused by PTSD. The Board has also considered whether PTSD presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2010); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology from his PTSD during each period in question, and provide for additional or more severe symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. For all the foregoing reasons, there is no basis for further staged rating of PTSD, pursuant to Hart, and the claims for increase 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 ratings, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to a rating in excess of 30 percent for PTSD, prior to October 8, 2009, is denied. Entitlement to a rating in excess of 50 percent for PTSD, from October 8, 2009 to May 28, 2010, is denied. Entitlement to a rating in excess of 70 percent for PTSD, from May 28, 2010, is denied. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs