Citation Nr: 1121383 Decision Date: 06/02/11 Archive Date: 06/09/11 DOCKET NO. 10-08 870 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) REPRESENTATION Veteran represented by: Ralph J. Bratch Esq., Bosley, McKown & Bratch WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran served on active duty from September 1966 to July 1968. Procedural History This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of the Indianapolis, Indiana, Department of Veterans Affairs (VA) Regional Office (RO), which, inter alia, granted service connection for PTSD and assigned a 30 percent evaluation, effective from October 15, 2007. The Veteran submitted a notice of disagreement with this assignment in January 2009, and timely perfected his appeal in March 2010. In August 2009, the Veteran and his spouse presented testimony before a Decision Review Officer (DRO). In August 2010, the Veteran and his spouse testified before the undersigned Acting Veterans Law Judge (AVLJ) during a Travel Board hearing. Transcripts of these proceedings are of record. Employability The Court of Appeals for Veterans Claims (Court) has recently held that a request for entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU), whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation. There must be cogent evidence of unemployability in the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009), citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). In the instant case, the holding of Rice is inapplicable since the evidence of record does not demonstrate that the Veteran has been rendered unemployable solely due to his service-connected PTSD. The Veteran himself has implicated his chronic obstructive pulmonary disease (COPD) as the primary factor leading to his retirement due to disability in 2005. Further, a March 2009 VA treatment record specifically stated that the Veteran was not employable due to his COPD. Thus, there is no cogent evidence of unemployability and entitlement to increased compensation based on TDIU is not warranted and need not be further considered at this point. See also Skoczen v. Shinseki, 564 F.3d 1319, 1323 (Fed. Cir. 2009) (the "support" requirement of section 5107(a) obligates the claimant to provide some evidentiary basis for his or her benefits claim). FINDINGS OF FACT 1. For the entire appeal period extending from October 15, 2007, the evidence reflects that the Veteran's PTSD has been productive of occupational and social impairment with reduced reliability and productivity with difficulty in establishing and maintaining effective work and social relationships, but has not been productive of occupational and social impairment with deficiencies in most areas and an inability to establish and maintain effective relationships. 2. The competent and probative medical evidence of record does not show that the Veteran's service-connected PTSD is so exceptional or unusual that referral for extraschedular consideration by designated authority is required. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial schedular evaluation of 50 percent for service-connected PTSD have been met for the entirety of the appeal period. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2010). 2. Application of the extraschedular rating provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010), requires VA to assist a claimant at the time that he files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Duty to Notify Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). With respect to the initial rating claim on appeal, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran dated in May 2008 (addressing the elements of service connection prior to the grant of service connection for PTSD). As this is an appeal arising from a grant of service connection, the notice that was provided before service connection was granted was legally sufficient and VA's duty to notify the Veteran in this case has been satisfied. See Hartman v. Nicholson, 483 F.3d 1311 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Subsequently, the RO readjudicated the claim in a statement of the case (SOC) issued in February 2010. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of fully compliant notification followed by readjudication of the claim, such as a SOC or Supplemental SOC, is sufficient to cure a timing defect). The Board concludes that during the administrative appeal process, the Veteran was provided the information necessary such that the purposes of the notification have been met. All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2010) (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his appellate claim, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. Duty to Assist The Board also finds that all of the relevant facts have been properly developed, and that all available evidence necessary for an equitable resolution of the issue on appeal has been obtained. The Veteran's service treatment and post-service treatment records were obtained and the file includes arguments, contentions and statements of the Veteran and his representative. The Veteran and his spouse provided testimony before a DRO and before the undersigned AVLJ in hearings held in August 2009 and August 2010, respectively. Records from the Social Security Administration (SSA) were sought and it has been confirmed for the record that no such evidence is available, as the Veteran is not in receipt of SSA disability benefits. See Baker v. West, 11 Vet. App. 163, 139 (1998) (VA's duty to assist includes obtaining SSA records when a veteran reports receiving SSA disability benefits, as such records may contain relevant evidence). VA's duty to assist includes obtaining an examination and medical opinion when necessary to make an adequate determination. See Duenas v. Principi, 18 Vet. App. 512 (2004). The Veteran was afforded a VA PTSD examination in September 2008 in connection with the claim currently on appeal. The Veteran's representative has contended that this examination is inadequate as it fails to comprehensively account for and address the lay and clinical evidence of record and contains inaccuracies, detailed by the Veteran in a January 2009 statement. Having reviewed the September 2008 VA examination report, which is 14 pages in length, in light of the concerns raised by the Veteran and his representative, the Board concludes that it is in fact adequate. That examination did not fail to account for lay assertions; in fact, it is clear that the Veteran's lay history and symptomatology were recorded and considered in conjunction with the examination and that the report was extremely comprehensive. Moreover, the examination report reflects review of the claims file (to include lay statements on file) and medical records in conjunction with the examination. Hence, assertions to the effect that the Veteran's overall history and lay evidence were not considered, and that the examination was based on an "inaccurate factual premise", are entirely unsubstantiated. With respect to alleged "errors" made by the examiner in conjunction with the 2008 VA examination, the Board notes that the Veteran's January 2009 statement of clarification has been considered. The alleged "errors" primarily consist of differences of opinion and clarification of matters of little or no import for rating purposes. Accordingly, the Board finds that the September 2008 VA examination report is thorough and supported by VA outpatient treatment records as well as the Veteran's lay statements. The examination in this case is adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Importantly, the Board notes that the Veteran is represented in this appeal. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has submitted argument and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. II. The Merits of the Claim The Veteran contends that the currently assigned 30 percent disability rating for his service-connected PTSD does not adequately reflect the severity of his disability. Governing Law and Regulations Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. §§ 3.102, 4.3. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2010). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2010); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in this case, the Veteran is appealing the initial assignment of a disability rating, and as such, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Under the general rating formula for mental disorders, to include PTSD, a 30 percent disability evaluation is warranted for: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with 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 disability evaluation is warranted 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability evaluation is warranted for: Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. A 100 percent disability evaluation is warranted for: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss of names of close relatives, own occupation, or own name. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM- IV), which VA has adopted, under 38 C.F.R. §§ 4.125 and 4.130, a GAF score of 61 to 70 denotes mild symptoms or some difficulty in social and occupational functioning. A GAF score of 51 to 60 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates serious symptoms or a serious impairment in social, occupational, or school functioning. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior, which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). Factual Background By rating action of November 2008, service connection was established for PTSD for which a 30 percent evaluation was assigned, effective from October 15, 2007, the date the original service connection claim for PTSD was filed. This case arises from an appeal of the initial rating assigned in that decision. In a September 2007 VA treatment note, the examining physician reported the Veteran's complaints of nightmares, flashbacks, and sleep impairment. Impulses were in good control and functioning was described as good. In November 2007, the Veteran's condition was described as improved and it was noted that the medications Citalopram and Alprazolam were very beneficial. An entry dated in January 2008, revealed that the Veteran was well-groomed. There were no indications of suicidal thoughts, aggressive behavior or delusions/hallucinations. Erratic and cycling episodes of anxiety, depression and sleep impairment were noted. Anxiety and depressed mood were described as mild. When seen in April 2008, the Veteran's condition was described as much improved. Anxiety and depressed mood were not demonstrated and judgment was described as good. The Veteran also indicated that his thoughts were positive. A July 2008 record indicates that the Veteran continued to have symptoms of nightmares, insomnia, flashbacks, irritability and anxiety. Anxiety and depressed mood were described as mild. Cognitive functions were intact and the veteran freely shared his thoughts and feelings. It was noted that the Veteran kept himself busy and exercised regularly. There were no suicidal or assaultive ideations and no psychotic symptoms. VA treatment records reflect that the Veteran underwent a psychiatric consultation in August 2007. The Veteran complained of a two-year history of symptoms including anxiety, nightmares, and sleep impairment. A written statement from the Veteran's wife detailing information similar to that provided in her 2008 lay statement mentioned below was provided for the examiner. The report indicated that the Veteran had been married for 9 years, as well as having children from several marriages. It was noted that he worked for the fire department from 1986 to 2005, at which time he retired due to medical disability. The report stated that the Veteran participated in leisure activities with friends including golf and bowling. On mental status examination, the Veteran was well-groomed and oriented. Anxiety and depressed mood, described as mild, were noted. Speech was normal and memory for recent and remote events was described as excellent. Thought processes were logical, and there was no indication of suicidal ideation or psychotic symptoms. The Veteran cried when relating an incident during service in which his best friend was killed in a tank explosion. It was noted that the Veteran participated well with others in leisure activities and that his social withdrawal and avoidance issues were not that problematic. Anxiety disorder was diagnosed. The file contains several lay statements dated in February 2008 and March 2008. The Veteran's wife provided one, indicating that she had known the Veteran for 30 years and had been married to him since 1998. She noted that the Veteran did not talk much about his Vietnam experience until he left the fire department. She mentioned that he had trouble trusting others including their children, and was suspicious of everyone. She stated that he had bad nightmares and flashbacks of Vietnam, also causing sleep impairment. She stated that he had crying spells and had lost interest in world events, activities, and relationships, and indicated that bowling was his only interest. It was noted that the Veteran always seemed depressed, was irritable, moody, and had a short fuse. She reported that the Veteran isolated, withdrew and was a loner. A second lay statement was offered by the Veteran's close friend, G.R.F., who reported that he had known the Veteran for 20 years and had met him through bowling. G.R.F. indicated that the Veteran had a startle response reaction to loud noises and noted that at times he was irritable and short-tempered. It was also noted that the Veteran had trouble concentrating and was easily distracted, and possibly experienced occasional flashbacks. G.R.F. also mentioned that the Veteran was difficult to get close to. A third statement was provided by P.D.M., who indicated that he had known the Veteran for 15 years and had been his close friend for the past 10 years. P.D.M. reported that he and the Veteran bowled, golfed and played cards together. The Veteran was described as hypervigilant, untrusting, irritable, cold, and dull. P.D.M. also mentioned that the Veteran was a loner and did not deal well with stress and tried to avoid stressful situations. It was noted that the Veteran experienced severe mood swings and road rage symptoms. The statement indicated that the Veteran had difficulty remembering names. A VA PTSD examination was conducted in September 2008; the claims file and medical records were reviewed. The report indicated that the Veteran retired on permanent disability due to COPD from the fire department in 2005, where he had worked for 18 years. VA records were summarized and the examiner referenced an entry dated in January 2008, at which time a GAF score of 64 was assigned; and an April 2008 record, reflecting that a GAF score of 71 had been assigned. On examination, the Veteran reported having symptoms of depressed mood, nightmares of Vietnam, and disturbed sleep. It was also noted that his physical health was not good due to COPD. The Veteran noted that he had several children and stepchildren from six marriages, with varying degrees of relationships. The Veteran described the relationship with his wife as close and positive. He also indicated that he had a few friends with whom he socialized, played golf and bowled, although he had not been currently bowling. The Veteran indicated that the level of his activities had been reduced due to COPD with trouble breathing, but reported that he was able to do lawn work and garden and had been using a treadmill. Mental status examination revealed that the Veteran was well groomed and oriented in all spheres. Memory and concentration were described as good. Speech and speech patterns were normal. The Veteran denied having psychotic symptoms such as hallucinations and delusions. The Veteran reported feeling depressed on examination and denied having any impulse control problems, panic attacks or obsessive/ritualistic behaviors. There was no indication of suicidal or homicidal thoughts or ideation. The Veteran noted that he experienced sleep impairment and distressing dreams of Vietnam. He also reported having a dislike of crowds and lack of involvement socially. The examiner noted that only mild psychosocial dysfunction could be attributed to PTSD-like symptoms. PTSD and adjustment disorder with depressed mood were diagnosed and a GAF score of 65 was assigned. The examiner summarized that overall, the Veteran was suffering from a mild case of PTSD with mild effect on his social and occupational functioning, as well as from adjustment disorder, which was independently responsible for some psychosocial functional impairment. The prognosis was good. A November 2008 VA record indicates that the Veteran reported that his symptoms were the same as when evaluated 3 months ago and that he continued to experience anxiety, flashbacks, nightmares, and irritability. Affect was partially restricted and anxiety and depressed mood were not apparent on examination. The Veteran indicated that he had not exercised since he retired (contrary to previous reports). Thought process was goal-directed, cognition was good and there was no indication of suicidal or assaultive ideation. The entry specifically indicated that the Veteran was adherent with his medications. In a statement dated in January 2009, the Veteran provided commentary and corrections relating to the September 2008 VA examination report. He indicated that his thoughts were not positive, his nightmares and flashbacks were getting worse daily, and that he was not totally adherent with his medications. He also indicated that while his activities were limited by COPD, the real reason for lack of social activities was his loss of interest in social activities, and distaste for being around other people. He mentioned that he continued to play golf in the summer. When seen by VA in February 2009, the Veteran reported that he was more depressed lately and mentioned it was during February that he had lost many friends in Vietnam. He stated that he isolated himself to a greater extent than usual during the holidays and did not know why he was experiencing increased flashbacks since he retired. A VA psychosocial assessment was conducted by a social worker in March 2009. It was noted that the Veteran was retired and that further employment was not feasible due to his COPD. The report indicated that the Veteran had been married for 11 years. It was noted that he felt that he was functioning on an average level, occasionally struggling with depression and tearful episodes. It was also reported that he had chronic symptoms of flashbacks and nightmares, occurring several times a week, resulting in a disrupted sleep pattern. PTSD was diagnosed. When seen in May 2009, the Veteran was appropriately groomed and speech was normal. The Veteran complained of sleep impairment and depression assessed as 5/10. Anxiety and depressed mood were described as mild, at best. There was no indication of suicidal, homicidal, or assaultive ideation. The entry specifically indicated that the Veteran was adherent with his medications. The assessment indicated that the Veteran was improving very satisfactorily. An August 2009 record indicates that the Veteran reported that he had been doing all right and presented with no problematic psychiatric issues. The Veteran was appropriately groomed and cognitive functions were normal. The Veteran mentioned that he exercised regularly with a treadmill, ate healthy foods and kept himself busy. Anxiety and depressed mood were not demonstrated. There was no indication of suicidal or homicidal ideation. The entry specifically indicated that the Veteran was adherent with his medications. The Veteran presented testimony at his DRO hearing in August 2009. At that time, the Veteran's representative made statements to the effect that the VA examination of September 2008 was inaccurate and inadequate and gave a summary of lay statements and VA clinical evidence in the file. The Veteran indicated that he did not like to be around people, because he did not trust them and was nervous. He indicated that he experienced symptoms of depression, irritability, crying spells, nightmares, flashbacks, and crying spells. He indicated that he had little social interaction and was not seeing his friends as frequently, or participating in activities such as bowling and golfing, explaining that he had quit doing these activities, because he did not want to be around other people. The Veteran indicated that his familial relationships were not strong with his children and grandchildren, whom he rarely saw. The Veteran's wife stated that her husband's depression seemed deeper and he was more withdrawn and isolated, to the point that she was taking vacations without him. VA records include an individual PTSD session record of September 2009. Screening revealed indications of mild depression, manifested by sleep impairment and little interest or pleasure in doing things, with no indication of suicidal ideation. When seen in November 2009, it was noted that the Veteran continued to struggle with sleep impairment and PTSD. The assessment indicated that the Veteran presented with chronic PTSD and heavily misplaced self-blame; he denied having suicidal/homicidal ideation. When seen later in November 2009, the Veteran reported that he continued to have nightmares, depressed mood, mild anxiety and sleep difficulty. Moderate PTSD symptoms were assessed. When seen in January 2010, the Veteran had complaints of depressed mood, anxiety, sleep impairment and nightmares. He indicated that he took Alprazolam, only as needed. The Veteran was appropriately groomed, speech was normal, and cognitive functions were good. It was noted that the Veteran was retired and was not as active as he used to be. Anxiety and depressed mood appeared mild. There was no indication of suicidal/homicidal ideation or psychotic symptoms. The entry specifically indicated that the Veteran was adherent with his medications. The Veteran presented testimony at a travel Board hearing held in August 2010. He stated that his symptoms included mood shifts, survivor guilt, sleep impairment, flashbacks, depression, and nightmares. He indicated that since retiring, he had too much time on his hands, and worked in the garden, but did not like to be around other people. The Veteran indicated that since 2007 he was not constantly depressed, but identified this as a primary manifestation of PTSD, with anxiety being a lesser symptom. He also mentioned having crying spells, occurring more than weekly. He indicated that his family relationships were growing more remote, with his wife still vacationing without him, and stated that he was no longer participating in activities such as bowling and golf. The Veteran explained that he was on five medications for PTSD and noted that he never had thoughts or impulses of hurting himself. His wife mentioned that the Veteran had symptoms of rage and speculated that he could do harm to someone in the right setting. She indicated that he had been constantly depressed since 2007. Analysis Since the Veteran filed his initial claim for PTSD in October 2007, VA records, VA examination reports, and lay evidence have reported the Veteran's symptoms of sleep impairment, nightmares, flashbacks, anxiety, and depressed mood. All of these symptoms are consistent with the enumerated criteria supporting both a 30 percent and a 50 percent evaluation. The Veteran's treatment records and the VA examination report fail to reflect any evidence of speech irregularities, short or long-term memory loss, panic attacks occurring more than weekly, difficulty in understanding complex commands, or impaired judgment or thinking; symptoms specifically enumerated in conjunction with the criteria warranting the assignment of a 50 percent evaluation for PTSD. However, disturbances of motivation and mood have been described, and evidence of difficulty in establishing and maintaining effective work and social relationships, supporting the assignment of a 50 percent evaluation have been documented. Significantly, the clinical evidence fails to reveal 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, and an inability to establish and maintain effective relationships, manifestations which if shown, would support the assignment of a 70 percent evaluation. The Veteran's representative has urged that lay statements and testimony presented by the Veteran, his wife and his friends be considered and maintains that these serve as a basis for the assignment of a 70 percent evaluation for PTSD. As an initial matter, the Board finds the lay statements presented by the Veteran's spouse and two friends to be both competent and generally credible, with exceptions explained herein. See also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). However, the lay statements and testimony fail to reveal evidence of 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); and an inability to establish and maintain effective relationships. The very fact that lay statements were presented by the Veteran's spouse, and two male friends, both of whom indicated that they had been close friends of the Veteran's for many years (15 to 20), fails to support a finding that the Veteran's PTSD is manifested by an inability to establish and maintain effective relationships. Significantly, while the lay statements revealed the Veteran's occasional irritability and anger; impaired impulse control, manifested by episodes of violence was not documented in those statements or in any clinical records. Hence, testimony of the Veteran's wife to the effect that she believed the Veteran could under certain circumstances, become violent, is merely speculative, lacking a basis in fact or history. In addition, during hearing testimony of 2010, the Veteran's wife stated that the Veteran had been constantly depressed since 2007; contrary to the Veteran's own testimony provided at that time, as well as clinical records which fail to support the testimony to that effect. Significantly, neither the lay nor the clinical evidence reflects that the Veteran has had suicidal/homicidal ideology or intent. Socially, while the evidence documents indications of isolation and social discomfort, it also reflects that the Veteran has been married for 11 years and that he generally has a stable and good relationship with his wife. This finding, in and of itself, is inconsistent with a demonstrated inability to establish and maintain effective relationships, as required to support a 70 percent evaluation. The evidence reflects that he interacts with at least some but not all of his family members, including grandchildren and at least one child. During the appeal period, the Veteran had been participating in activities including gardening, card playing, bowling and golf, and had spent time with two good friends; however according to the Veteran he had scaled back his social activities because he did not like to be around people. The Board is aware that the Veteran's disinterest in socialization and social activities appears to have trended downward during the appeal period, coincident with the pursuit of additional compensation for his PTSD. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) [personal interest may affect the credibility of testimony]. Overall, it does appear, however, that the Veteran has some social impairment and difficulty getting along with others, consistent with difficulty in establishing and maintaining effective work and social relationships as contemplated under the rating criteria supporting a 50 percent evaluation for PTSD. Industrially, the evidence reflects that the Veteran worked for the fire department from 1986 to 2005, at which time he retired due to medical disability, identified as COPD. There is no indication that PTSD had any role with respect to the Veteran's decision to retire or that it was even diagnosed at that time. Documentary evidence does not reflect, nor has lay evidence been provided, to the effect that PTSD is productive of occupational impairment with deficiencies in most areas, consistent with the assignment of a 70 percent evaluation. Significantly, throughout the appeal period, the file contains assigned GAF scores ranging from 64 to 71. Such scores are indicative of mild symptoms or some, but less than moderate, difficulty in social and occupational functioning. Such scores are not comparable with the assignment of an evaluation in excess of 50 percent for PTSD, and arguably fail to support the assignment of that rating. Since October 2007, the lay and clinical evidence demonstrates several of the enumerated criteria consistent with assignment of both 30 percent and 50 percent disability evaluations for PTSD. Further, the GAF scores assigned during the appeal period have been indicative of mild to, at most, moderate impairment. In light of the aforementioned evidence and with the application of the benefit of the doubt in the Veteran's favor, the Board finds that the Veteran's service-connected PTSD more nearly approximates the criteria for an initial 50 percent evaluation under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411, as occupational and social impairment with reduced reliability and productivity with difficulty in establishing and maintaining effective work and social relationships is arguably demonstrated. 38 C.F.R. § 4.7 (2010). As already explained herein, the evidence fails to show essentially all of the enumerated criteria warranting the assignment of a 70 percent evaluation. Similarly, none of the enumerated criteria consistent with the assignment of a 100 percent schedular evaluation for PTSD has been shown. In this regard, neither lay nor clinical evidence documents symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss of names of close relatives, own occupation, or own name. In light of the aforementioned evidence and with the application of the benefit of the doubt in the Veteran's favor, the Board finds that the Veteran's service-connected PTSD more nearly approximates the criteria for the assignment of an initial 50 percent evaluation under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411, indicative of occupational and social impairment with reduced reliability and productivity with difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.7 (2010). Resolving reasonable doubt in the Veteran's favor as to the severity of service-connected PTSD, the Board concludes that the criteria for an initial 50 percent evaluation are met for the entirety of the appeal period extending from October 15, 2007, forward, and to this extent, the appeal is granted. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). However, the preponderance of the evidence is against the assignment of an initial evaluation in excess of 50 percent for any portion of the appeal period. Since the evidence relating to this specific matter is not in equipoise, the provisions of 38 U.S.C.A. § 5107(b) regarding resolution of reasonable doubt are not applicable. III. Extraschedular Consideration The Board also recognizes that the Veteran and the record refer to the impact of PTSD on the Veteran's work functioning. In general, the schedular disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service, for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe a veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate a veteran's level of disability and symptomatology, then either the RO or the Board must determine whether a veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, the symptoms and manifestation described by the lay and clinical evidence fit within the criteria found in the relevant diagnostic code (9411) used for evaluating PTSD. In short, the rating criteria contemplate not only the symptoms but also the severity of the disability. With respect to interference with employment, as mentioned herein, the Veteran has been retired since 2005 due to disability, identified as COPD, with no indication that PTSD (undiagnosed at that time) was also a factor. In addition, although it is shown that the Veteran receives regular VA treatment for PTSD, there is no evidence of frequent, or in fact any hospitalizations, for this condition. For these reasons, referral for extraschedular consideration is not warranted. ORDER Subject to the provisions governing the award of monetary benefits, an initial disability evaluation of 50 percent for PTSD is granted for the entirety of the appeal period extending from October 15, 2007. ____________________________________________ K.A. KENNERLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs