Citation Nr: 1124483 Decision Date: 06/28/11 Archive Date: 07/06/11 DOCKET NO. 07-34 659 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently rated as 50 percent disabling. REPRESENTATION Appellant represented by: Robert Chisholm, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T.S. Willie, Associate Counsel INTRODUCTION The Veteran had active service from December 1965 to September 1967. This matter comes before the Board of Veterans' Appeals (Board) from a June 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified before the undersigned Acting Veterans Law Judge at the RO in April 2010. A transcript of the hearing has been associated with the record. In July 2010, the Board granted a rating of 50 percent disabling for PTSD but denied a rating higher than 50 percent disabling. Thereafter, the Veteran filed an appeal to the United States Court of Appeals for Veterans Claims (Court). The Veteran's representative and VA General Counsel also filed a Joint Motion for Remand (Joint Motion). In December 2010, the Court granted the Joint Motion for remand and remanded the claim. FINDINGS OF FACT 1. Prior to January 20, 2011, PTSD was manifested by sleep disturbances, nightmares, impaired impulse control, obsessional rituals, isolation, intrusive thoughts, depression, and a GAF score range of 50 to 55. 2. On and after January 20, 2011 PTSD is manifested by deficiencies in judgment, thinking, family relations, work and mood, and a GAF score range of 45. CONCLUSIONS OF LAW 1. Prior to January 20, 2011, the criteria for an evaluation of 50 percent, but no higher, for PTSD were met. 38 U.S.C.A. § 1155 (West 2002 and Supp. 2010); 38 C.F.R. § 4.130; Diagnostic Code (DC) 9411 (2010). 2. On and after January 20, 2011, the criteria for an evaluation of 70 percent, but no higher, for PTSD are met. 38 U.S.C.A. § 1155 (West 2002 and Supp. 2010); 38 C.F.R. § 4.130; Diagnostic Code (DC) 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2010), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Prinicpi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial disability-rating and effective-date elements of a service connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the originating agency provided the Veteran with the notice required under the VCAA by a letter dated in January 2007. The Veteran was provided with additional notice regarding the specific criteria for rating the disabilities on appeal in June 2008. This more than satisfies VA's notice requirements, as notice described in 38 U.S.C. § 5103(a) need not be veteran-specific. Generic notice is all that is required under Paralyzed Veterans of America v. Secretary of Veterans Affairs, 345 F.3d 1334 (Fed. Cir. 2003); and Wilson v. Mansfield, 506 F.3d 1055 (Fed. Cir. 2007). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009). In connection with the current appeal, appropriate examinations have been conducted and available service records have been obtained. We also note that the VA examinations were adequate. The examiner's reviewed the history, established clinical findings and presented reasons for the opinions. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim. The evidence of record provides sufficient information to adequately evaluate the claim, and the Board is not aware of the existence of any additional relevant evidence which has not been obtained. No further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). Accordingly, the Board will address the merits of the claim. Legal Criteria and Analysis Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2010). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Here, as shown below, the Board finds that the appellant's disability has significantly changed and that a staged rating is warranted. The Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under-or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. See 38 C.F.R. § 4.126 . If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). The Veteran's PTSD is evaluated pursuant 38 C.F.R. § 4.130 Diagnostic Code 9411, and is subject to the criteria listed under the General Rating Formula for Mental Disorders. The General Rating Formula provides a 10 percent evaluation for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130 (2010). The rating formula provides a 30 percent evaluation 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, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty 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 or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 100 percent evaluation is indicated where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. 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. 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. In assessing the evidence of record, it is important to note that the GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 31 to 40 is assigned where there is 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 younger children, is defiant at home, and is failing at school). Id. A score of 41-50 is assigned where there are 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). Id. A score of 51-60 is assigned where there are 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, conflict with peers or co- workers). Id. A score of 61-70 is indicated where there are 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. Id. PTSD Prior to January 20, 2011 The Veteran appeals the denial of a rating higher than 50 percent disabling for PTSD prior to January 20, 2011. The 50 percent rating contemplates occupational and social impairment with reduced reliability and productivity. To warrant a 70 percent rating the evidence must show occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. During this time period, a VA outpatient treatment record dated in August 2005 showed the Veteran indicated that his most significant problem was sleep. He did not feel depressed and did not identify any problems associated with anxiety. He preferred to be alone. On mental status examination, he had appropriate grooming and hygiene. He was very guarded and suspicious in his response to questions asked regarding his symptoms. His speech was normal. His mood appeared very depressed based on facial expression and body posture. His affect was extremely constricted. The thought-process was logical and goal-directed with intact associations. There were no hallucinations or delusions. He had no suicidal or homicidal ideation. His insight and judgment were fair. His cognition was difficult to assess due to minimal response to questions. The Axis I diagnosis was PTSD. A September 2005 VA outpatient treatment report notes that the Veteran continued to just stare at the examiner with absolutely no change in facial expression. He stated that he did not feel depressed but his facial and body language were in total conflict with his comments. When questioned regarding thoughts of suicide, he stated that his last thoughts occurred four to five years ago and that he had no history of attempts. He denied any paranoid, auditory, or visual hallucinations. His affect was extremely constricted and his degree of depression was certainly congruent. On mental status examination, he had appropriate dress and grooming. His psychomotor activity was unremarkable. The examiner had to force him to respond to questions but when he did respond his speech was logical and congruent. His form of thought was very difficult to assess but he did not exhibit any symptoms of psychosis. He had no paranoia, obsessions, or any active delusional system exhibited at least not during his visit. He denied auditory and visual hallucinations and there was no overt impairment in judgment and insight observed. His memory functioning was difficult to assess. His attention and concentration was adequate. He denied suicidal and homicidal ideation. The diagnosis was depression and PTSD (less observed than depression). In a July 2006 VA compensation and pension examination report, the Veteran reported nightmares with varying frequency, isolation, flashbacks, avoidance of crowds and a bad temper. He also reported that he lived alone and never goes outs for leisure. The Veteran stated that he had problems with getting along with his coworkers and that he has been reprimanded three or four times for getting angry at others. He admitted to problems on the job due to effects of his drinking. He related that he thought his marriage was good but his wife left him because of his temper. It was noted that he had poor relationships with his children and grandchildren, and that he had no friends. The Veteran stated that he does nothing for fun and that he lost interest in hunting, fishing, and camping after he returned home Vietnam. Past suicidal ideations were noted but the Veteran denied present suicidal ideation, plan or intent. Examination revealed the Veteran was alert, well oriented with a slightly hostile/angry mood. It was noted that the Veteran had spontaneous verbalizations problems which made evaluation difficult. He reported poor concentration but denied hallucinations. He denied suicidal ideation but reported homicidal thoughts on a daily basis with no plan or intent. He reported road rage. There was no evidence of problems with personal hygiene. He denied memory problems and did not evidence such. He could not identify obsessive or ritualistic behavior, which interfered with his daily activities. He admitted to sometimes returning home to check the doors at home but could not say how often this happened. It was noted that the Veteran appeared to experience some depression but it was difficult to evaluate if it is a primary condition or secondary to his PTSD. His flat affect, feelings of sadness most of the time, lack of interest in anything pleasurable, and problems with concentration indicated the possibility of depression. He also had sleep disturbance due to nightmares. The Axis I diagnosis was PTSD, delayed onset. A GAF score of 54 was assigned. The examiner noted that the Veteran's flat affect, lack of friendships and conflicts with peers and coworkers puts him in the range of moderate symptoms. The VA examiner noted that current psychological functioning was sub-optimal. The examiner noted that the Veteran continued to experience significant distress and difficulties with sleeping, nightmares, temper control, occupational problems, flashbacks, poor relationships both familial and social, isolation, intrusive thoughts and depression. The examiner noted that it appears that the Veteran's problems with psychosocial functioning and quality of life are directly related to his PTSD. It was noted that the Veteran had not indicated that his symptoms have worsened significantly in the past year. The examiner related that the prognosis of improvement in psychiatric functioning was guarded to poor. The Veteran was afforded a VA compensation and pension examination in May 2007. The examiner noted that there were no significant changes in medical or psychiatric history since the last detailed examination. It was noted that there was no PTSD treatment over the last year. It was noted that the Veteran stated that the frequency and severity of psychiatric symptoms had stayed the same with no remissions. There were complaints of nightmares, sleep disturbances and isolation. Examination revealed no impairment of thought process or communication, delusions, and suicidal or homicidal ideations. Personal hygiene was adequate and eye contact good. Orientation was times four. He had no remote or recent memory loss, was cognitively alert, and had good concentration. There was no obsessive or ritualistic behavior reported. His speech was monotone and truncated. He reported impulse control problems in the past and sleep disturbances from nightmares. There were no panic attacks and the Veteran denied depression. The examiner noted that the Veteran presented in an antisocial passive aggressive stance which had been documented. It was noted that his affect was flat. He reported that he worked for 29 1/2 years as a forklift operator for M&M Mars and that other workers considered him of short temper and left him alone. He reported that he drinks five or more beers to help him sleep. The Veteran reported that he chooses to live alone and that he had no friends or recreational activities. PTSD was diagnosed and a GAF score of 55 was assigned. The examiner noted that PTSD is not found to be contributing to any decrease in work efficiency as the Veteran reported he quit his job because they were going to decrease his benefits. The examiner noted that the Veteran's choice not to perform occupational tasks was due to his own free will and to his personality disorder characteristics. It was noted that he worked for almost 30 years with apparently satisfactory functioning before resigning. The examiner reported that that the Veteran's social and family dysfunction are also related to his choice of oppositional behaviors and cannot be attributed to PTSD for which he has chosen not to obtain therapy since February 2006 over the past year. Examination in December 2007 revealed the Veteran had normal affect, mood, judgment and comprehension, and appropriate behavior. There were no obsessive behavior and/or hallucinations/delusions. In a January 2008 VA compensation and pension examination report, current psychiatric symptoms were noted to include repeated nightmares, irregular sleep pattern, and drinking. It was noted that the Veteran was a poor historian and was not interested in volunteering to present his symptoms. He was not interested in social interactions and had poor frustration tolerance with quick loss of temper and development of passive homicidal ideations. The Veteran did not feel safe and it was noted that he did not trust others including family. It was noted that he lived alone on 12 acre land. He kept his guns by his bed and behind his doors and frequently checked his house and doors. He was unable to trust anyone even his family. He reported that his children hardly visit him but he sometimes visits them on special occasions. It was noted that he overall has poor quality of relationships with others and has no interest in developing new relationships. He related that used to have friends but they have died by this time. The Veteran denied having any leisure interests but it was noted that once or twice a year he goes to rodeos. It was noted that he has poor quality family role functioning and social and interpersonal relationships and it appears that he had limited ability to adjust to new environments. With respect to his work history, the Veteran indicated that he quit his job in August 2006 to avoid being downsized. He did not apply for another job, as he thought he had worked enough and was not comfortable going to interviews or getting used to a new set of people or job environment. However, he did not feel that his PTSD symptoms were contributing directly to him not finding a job. The examiner noted that the Veteran did not demonstrate any abnormal psychomotor activities but demonstrated generalized disinterest. His mood was undescribed with somewhat restricted and dysphoric affect. It was noted that he had no ongoing suicidal or homicidal thoughts, and that he was able to maintain minimal personal hygiene in daily living. He was well oriented to time, place, person and situation. There were no gross memory deficits, panic attacks, and/or impaired impulse control. He had obsessive and ritualistic behaviors. His speech was minimal in spontaneity and brief in answers. PTSD was diagnosed and a GAF score of 50 was assigned. The examiner noted that the Veteran appeared to have more social isolation and was unemployed by choice of retirement. The examiner noted that there was reduced reliability and productivity due to PTSD signs and symptoms but found that the Veteran's ability to function in a normal occupational environment was not directly impaired from his PTSD symptoms. During his April 2010 hearing, the Veteran reported nightmares. He also stated that he did not leave the house much. He related that he saw his family about once or twice a year and that he did not have a lot of company. He testified that he quit his last job because he was going to get fired. He indicated that he had an angry outburst with a Vietnamese co-worker and decided to retire instead of getting fired. Based on the evidence of record, the Board finds that a rating higher than 50 percent disabling for PTSD for this period of time is not warranted. In this regard, there is no indication of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran's mood was described as "very depressed" by the August 2005 VA examiner and depression was further noted in subsequent VA examination reports, demonstrating a deficiency in mood. However, his thought process was goal-directed and logical and he had no overt impairment in judgment. Although there was a showing deficiencies in family relations as it was shown that his wife left him because of his temper and that he had a poor relationship with his children and grandchildren, the VA examiner in May 2007 found that the social and family dysfunction was related to his choice of oppositional behaviors and his decision not to obtain therapy since February 2006. With respect to work impairment, the May 2007 VA examiner found that the Veteran's PTSD was not found to be contributing to any decrease in work efficiency, as the Veteran reported that he quit his job because they were going to decrease his benefits. Despite his reports of problems with getting along with his coworkers and that he had been reprimanded three or four times for getting angry at others, the Veteran nevertheless admitted to problems on the job due to effects of his drinking not his PTSD. We note that the Veteran has reported some inconsistencies regarding why he was not working. On some VA treatment records, he indicated that he quit to avoid being laid off due to downsizing. However, in the hearing, he testified that he had an angry outburst with a co-worker and quit to avoid being fired. The January 2008 examiner specifically commented that he is a poor historian. While the Veteran is competent to report his symptoms, the record shows that he was an unreliable historian. Therefore, the probative value of his statements and assertions regarding his symptoms are diminished. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). While the Veteran's PTSD has been shown, albeit not necessarily in a consistent pattern, to be manifested by such symptoms as sleep disturbances, nightmares, impaired impulse control, obsessional rituals, isolation, intrusive thoughts and depression, such findings do not warrant a 70 percent evaluation when all the other manifestations are considered. See Mauerhan, 16 Vet. App. at 443. Examination revealed that the appellant was oriented and there were no gross memory deficits, panic attacks, impairment of thought process or communication, or delusions. He was also able to maintain minimal personal hygiene in daily living. Moreover, the evidence shows that the appellant was unemployed by retirement. These findings do not justify a 70 percent rating. It is clear that the evidence shows deficiencies in family relations and mood. However, the evidence for this period of time shows that the criteria contemplated for a 70 percent rating under DC 9411 have not been demonstrated. The more probative evidence shows that the Veteran's disability was no more than 50 percent disabling for this period of time. The observation of the skilled professionals, consisting of a thorough compensation and pension examination and numerous reports of outpatient visits, are more probative than the Veteran's own characterization of his disability. Furthermore, while an examiner's classification of the level of a psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage disability rating to be assigned (38 C.F.R. § 4.126), it is notable that for the period considered in this appeal the Veteran's GAF scores have ranged between 50 and 55, denoting moderate to serious impairment. In the view of the Board, such a characterization of the PTSD is consistent with the assignment of a 50 percent rating and no more. In short, prior to January 20, 2011 the Veteran's symptoms were more characteristic of a disability picture that was contemplated by a 50 percent rating than that contemplated by a 70 percent rating under Diagnostic Code 9411. The medical and lay evidence as well as the GAF scores establish that there was occupational and social impairment occupational and social impairment with reduced reliability and productivity during this period of time. However, the manifestations do not establish occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. For all the reasons set forth above, the preponderance of the evidence is against a rating higher than 50 percent disabling for PTSD prior to January 20, 2011. PTSD On and After January 20, 2011 Based on the evidence of record, the Board finds that the criteria for a 70 percent rating for PTSD have been met on and after January 20, 2011. In this regard, the Veteran was afforded a VA compensation and pension examination in January 2011. During this examination, the Veteran reported continued symptoms of PTSD but indicated that he was not involved in treatment because he did not find it effective. He continued to report nightmares, flashbacks, hypervigilance, low frustration and anger. He continued to report that he speaks to his children only 2-4 times per year and that he was not involved in any relationship. He expressed that he was not interested in developing new relationships and currently had no friends at all. He reported that he attended rodeos once or twice a year but that he did not engage in any other activities. He continued to deny any episodes of violence since the 1970s. He lived alone. It was noted that he was isolative, preferring to be alone. His social interaction was severally impaired and he reported that he continued to drink 5-6 beers per day to help with his PTSD symptomatology. There was no reported history of suicide attempts. Examination revealed the Veteran had a clean general appearance, tense psychomotor activity, unremarkable speech, constricted affect and agitated/labile mood. His attention was intact as he was able to do serial 7s and able to spell a word forward and backward. He was oriented to person, time and place. His thought process and thought content was unremarkable, and he was without delusions and/or hallucinations. He understood the outcome of his behavior and had below average intelligence. He partially understood that he had a problem and did not have inappropriate behavior. He reported obsessive/ritualistic behavior in that he checked his shop and doors to make sure that they were locked. There were no reported panic attacks. He denied homicidal thoughts but reported suicidal thoughts. He denied intent or plan. He had fair impulse control and no episodes of violence. It was reported that he did not have the ability to maintain personal hygiene. There was no problem with activities of daily living, and his memory was normal. His PTSD symptoms included recurrent and intrusive distressing recollections, avoidance of thoughts, feelings and conversations, difficulty falling or staying asleep, irritability, hypervigilance and exaggerated startle response. It was noted that the Veteran worked as a factory worker but was retired. The reason stated was medical, psychiatric problem. He reported having conflict with his coworkers and indicated that it was difficult to get along with other people. Chronic PTSD was diagnosed and a GAF score of 45 was assigned. The Veteran denied that any of his symptoms have increased but remained consistent. The examiner noted that the Veteran continued to remain isolative with no social interaction and that he was able to maintain daily tasks and personal hygiene. The examiner found that there was no total occupational and social impairment due to PTSD signs and symptoms but that there were deficiencies in judgment, thinking, family relations, work and mood. The examiner related that the Veteran reported difficulty resolving conflict which led to his inability to maintain employment, a mistrust of others, limited interaction with his children and grandchildren and no employment since 2006. He also noted that the Veteran reported that he is often empty and is easily irritated with others. In April 2011, a vocational consultant, E.J. C., related that the Veteran maintained steady employment throughout July 2006 but that the records show that he had difficulty with personal, social, and occupational relationships far before this. He stated that the Veteran's PTSD excludes occupations where dealing with the general public and certain co-workers and supervisors are involved. Here, on and after January 20, 2011, the evidence shows occupational and social impairment with deficiencies in most areas, such as judgment, thinking, family relations, work and mood. During this time frame, the Veteran reported nightmares, flashbacks, hypervigilance, low frustration, anger, minimal contact with his children, no friends, lack of involvement with any relationship and no desire to develop new relationships, that he lived alone and attendance of rodeos one or twice a year but no other activities. However, he has further reported obsessive/ritualistic behavior. It has also been shown that he does not have the ability to maintain personal hygiene. We also note that while he denied homicidal thoughts, he reported suicidal thoughts. Furthermore, the VA examiner found that the Veteran's PTSD signs and symptoms caused deficiencies in judgment, thinking, family relations, work and mood. These findings justify an evaluation of 70 percent disabling during the applicable time frame as there is a showing of deficiencies in most areas, such as work, family relations, thinking and judgment due to such symptoms as suicidal ideation, obsessional rituals which interfere with routine activities, impaired impulse control, neglect of personal appearance and hygiene, and the inability to establish and maintain effective relationships. Furthermore, while an examiner's classification of the level of a psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage disability rating to be assigned (38 C.F.R. § 4.126), it is notable that for the period considered in this appeal the Veteran's GAF score was 45, denoting serious impairment. In the view of the Board, the GAF score is consistent with the Veteran's PTSD symptomatology and the assignment of a 70 percent rating. However, we find that an evaluation higher than 70 percent disabling is not warranted. The Veteran retains the ability to maintain daily tasks. Examination has also revealed that his attention was intact, memory normal, he was oriented times three and with unremarkable thought process and thought content. He was without delusions, hallucinations, and inappropriate behavior. Although he reported suicidal thoughts, he denied intent or plan. We also note that the January 2011 VA examiner found that there was no total occupational and social impairment due to PTSD signs and symptoms. Such findings do not warrant a 100 percent evaluation when all the other manifestations are considered. See Mauerhan, 16 Vet. App. at 443. In sum, the appellant's symptoms are more characteristic of a disability picture that is contemplated by a 70 percent rating and no more during this time period. An inferred claim for a TDIU under Rice v. Shinseki, 22 Vet. App. 447 (2009) also has been considered. The evidence, particularly most recently, shows significant occupational impairment due to the Veteran's PTSD. The Veteran reported difficulty resolving conflict which led to his inability to maintain employment. However, the medical evidence does not demonstrate that the Veteran is unemployable as a result of his PTSD. The January 2011 examiner found that there was no total occupational impairment due to PTSD signs and symptoms. The April 2011 vocational consultant stated that the Veteran's PTSD excludes occupations where dealing with the general public and certain co-workers and supervisors are involved, but did not find that any job was not feasible. Therefore, any inferred TDIU claim is inapplicable in this case. We have also considered referral for an extraschedular rating. Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. Here, the Board finds that the record reflects that the Veteran has not required frequent periods of hospitalization for his disability and that the manifestations of the disability is contemplated by the schedular criteria. Therefore, there is no reason to believe that the average industrial impairment from the disability would be in excess of that contemplated by the schedular criteria. Therefore, referral of the case for extra-schedular consideration is not in order. ORDER Entitlement to a rating higher than 50 percent for PTSD prior to January 20, 2011 is denied. Entitlement to a rating of 70 percent, but no higher, for PTSD on and after January 20, 2011 is granted, subject to the rules and payment of monetary benefits. ____________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs