Citation Nr: 1124756 Decision Date: 06/29/11 Archive Date: 07/06/11 DOCKET NO. 05-06 595A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to December 3, 2009. 2. Entitlement to a rating in excess of 70 percent for PTSD from December 3, 2009. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from March 1942 to October 1942, from May 1943 to October 1948, and from October 1950 to August 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2004 rating decision by the Huntington, West Virginia Regional Office (RO) of the Department of Veterans Affairs (VA), which granted service connection for PTSD and assigned a 50 percent rating for the disability. In August 2009, the case was remanded to the RO, via the Appeals Management Center (AMC) for further development. In a subsequent April 2011 decision, the AMC granted an increased, 70 percent rating, for PTSD effective December 3, 2009. A total rating based on individual unemployability was also granted in this action. The matter at issue then concerns the schedular criteria. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Prior to December 3, 2009, the Veteran's PTSD was manifested by symptoms of difficulty sleeping, nightmares, flashbacks, exaggerated startle response, agitation, depressed mood, anxiety, survivor guilt, guardedness, suspiciousness, difficulty concentrating, memory impairment, avoidance of crowds, irritability, intrusive thoughts of past trauma, difficulty dealing with stress, tiredness, poverty of thoughts, low self-esteem and panic attacks as often as two or three times per week. These symptoms resulted in occupational and social impairment with reduced reliability and productivity. Occupational and social impairment with deficiencies in most areas was not shown. 2. From December 3, 2009, the Veteran's PTSD has been manifested by symptoms of intrusive thoughts, sleeping problems, flashbacks, nightmares, exaggerated startle response, anxiety, mood problems, significant memory problems, concentration difficulty, mild cognitive impairment and inability to manage his VA benefits on his own. These symptoms have resulted in occupational and social impairment with deficiencies in most areas. Total occupational and social impairment has not been shown. CONCLUSIONS OF LAW 1. Prior to December 3, 2009, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2010). 2. From December 3, 2009, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2009) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2009). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim, as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In the present case, the Board finds that VA has satisfied its duty to notify. By way of VCAA notice letters sent to the Veteran in March 2006 and September 2009 the RO generally informed the Veteran of the evidence necessary to substantiate his claims and his and VA's responsibilities in claims development. Also, the Veteran was informed that in evaluating his disabilities, VA would consider evidence of the nature and symptoms of his condition; the severity and duration of his symptoms; and the impact of his condition and symptoms on employment. Additionally, he was notified of the general manner in which disability ratings are assigned, and examples of the types of evidence he could submit, or ask VA to obtain, were also provided. Further although this notice was provided after the initial rating decision, the Veteran was not prejudiced by this timing because the case was subsequently readjudicated by an April 2011 supplemental statement of the case. No further notice action is necessary. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the Veteran's claim. Pertinent medical evidence associated with the claims file consists of VA treatment records, Veteran's Center records, the report of a private psychiatric examination and the reports of VA psychiatric examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran, and by his representative on his behalf. The Board notes that no further RO action, prior to appellate consideration of the claim is required. II. Factual Background A January 2004 Veteran's Center report from a treating social worker shows that the Veteran was found to present with chronic PTSD symptoms including significant anhedonia, intense flashbacks to World War II, intrusive thoughts, insomnia, nightmares, hypervigilance and impaired impulse control. He described a life of isolation, avoidance, mild paranoia, mistrust, suspiciousness, poor memory and concentration. At times he had great difficulty in controlling his anger outbursts that would often manifest as aggressive and threatening behavior directed toward his family and those around him. If he felt threatened, trapped or cornered, he would lash out. The reporting social worker noted that a significant amount of group therapy for the Veteran was devoted to cognitive restructuring to reduce his anger and rage outbursts. The Veteran was noted to have pervasive feelings of helplessness, hopelessness, guilt, and worthlessness. He experienced flashbacks and recollections of trauma experienced in combat at least two to three times weekly. He also experienced nightmares on a weekly basis. When awakened from sleep, he often performed a perimeter check of his home to insure that it was safe and secure. Overall, the Veteran's symptoms were considered severe. He felt angry, anxious and depressed when reminded of events from the war and he did not watch television programs or movies about the war. The Veteran was also noted to experience difficulty maintaining social relationships and avoided places where there were crowds. He had few friends and rarely participated in family activities. He described himself as a loner and had very limited interests or hobbies. He had reported that he was close to no one, not even family members and preferred spending his time alone but was unable to do so because he was highly dependent on his wife. The social worker noted that when the Veteran was upset, confused or pressured, he continued to display spatial disorientation that resulted in a dissociative state. His speech remained circumstantial and stereotyped. For example, the symptoms he presented with were the same every week. The social worker also noted that the Veteran's speech delivery was retarded in pace but coherent. The Veteran's affect was most often flat and his mood was often anxious and depressed. In regard to hyperarousal symptoms, his insomnia, irritability, concentration, memory problems and hypervigilance were considered severe. The social worker diagnosed the Veteran with PTSD and depression. He found evidence of severe impairment in both the social and vocational areas. He noted that the Veteran's depressive symptoms were sequelae of his PTSD. He noted symptoms of re-experience, avoidance, irritability, numbing, hyperarousal, depressed and anxious mood, mild paranoia, panic attacks, survivor's guilt, social isolation, avoidance and mistrust. The social worker noted that the Veteran currently had adequate social supports to sustain him. However, the supports were fragile in nature. He rated the Veteran's functioning as guarded and noted that he was not a candidate for future employment. He also found that the Veteran was in the top 10 of Veterans he had treated in terms of the severity of his symptoms. The diagnoses were PTSD, delayed onset with some disassociation and depression. The social worker found that the Veteran experienced social isolation, inability to maintain effective social and work relationships and health concerns. On September 2004 VA psychiatric examination, the Veteran reported difficulty sleeping, nightmares, flashbacks, exaggerated startle response, and agitation. He was noted to be depressed and anxious with some survivor guilt. He and his wife were sleeping in separate rooms as she could not stand his moaning, shouting, and screaming in his sleep. He was also noted to have three children living in different parts of the country with whom he had some limited contacts. Mental status examination showed that the Veteran exhibited a dysphoric mood. There was no evidence of psychosis, thought disorder, bizarre thoughts, or tangential circumstantiality. There were no active suicidal ideations or intent. His memory was fair most of the time but he had difficulty in recall, especially recalling only four digits forward and three digits backwards. He also had difficulty remembering his name and address after two and five minutes. He reported that he was simply unable to concentrate. However, no definite clinical evidence of cognitive disorder was elicited. The Veteran was a little guarded and suspicious and there was no evidence of psychosis or thought disorder. There were no auditory or visual hallucinations elicited. There was also no active homicidal or suicidal ideation or plans entertained. Insight and judgment in problem solving seemed to be fair. The Veteran reported that he had no particular hobbies but he did go to church regularly. He did not belong to any club or association. He was able to take care of personal chores and hygiene. The diagnoses were PTSD, mild to moderate and depressive disorder, not otherwise specified. The Veteran was also noted to have diabetes, history of arthritis, chronic low back pain, history of hypertension, and hypothyroidism. The examiner assigned a GAF score of 50. The Veteran was noted to be competent to handle his financial affairs. An October 2004 VA psychiatric consultation shows that the Veteran reported nightmares, avoidance of crowds, difficulty concentrating, and irritability. He indicated that every day he had thoughts of his experiences in combat and in the military. He felt that it was difficult to trust people. He felt anxious, and reported nightmares probably two times per month. He only slept about four hours per night. He cried easily if he was reminded of service. He was easily startled and would sit with his back against the wall in restaurants. If he went into a new building, he had to know where the exits were so that he could leave at any time. He state that approximately one year prior he had been started on Ambien from his outside physician that he took about two to three times a week. He had been going to the Veteran's Center in Princeton and noted that a PTSD class there had been helpful. The Veteran reported that he liked to read the Bible and liked to work on his computer. He also liked to get out and go for a drive to different places. He denied any suicidal or homicidal ideations. He also denied auditory or visual hallucinations. Mental status examination showed that the Veteran was a 78 year old Caucasian male who was cooperative and pleasant. He was alert and oriented to all parameters. He was casually dressed with good hygiene. He appeared to be well-groomed. His mood was a bit anxious and his affect was narrow but appropriate. He also maintained good eye contact and initiated conversation. He smiled appropriately and his speech was clear, concise, and goal-directed. His thought content was not psychotic or dangerous and his intellect appeared above average. His sensorium appeared clear and his insight and judgment into his illness was fair. His immediate, recent and remote memory appeared intact. The diagnostic assessment was PTSD and a GAF score of 60 was assigned. A December 2004 VA mental health clinic progress note shows that the Veteran was having nightmares occasionally and "crazy dreams" quite often. He often had thoughts of his past trauma, along with flashbacks, during the day. He had been trying to limit his intake of the news concerning Iraq. He was also going to the Veterans Center, which was helpful. He was feeling less depressed and was not feeling anxious. He denied suicidal or homicidal ideation. Mental status examination showed that the Veteran was pleasant, cooperative, casually dressed, well groomed and had good hygiene. His mood was slightly anxious. His affect was appropriate. He maintained good eye contact, initiated conversation and smiled appropriately. His speech was clear, concise and goal directed. His thought content was not psychotic or dangerous. His intellect appeared above average. Insight and judgment into his illness were fair. His cognitive function appeared intact. Immediate, recent and remote memory also appeared intact. The diagnostic assessment was PTSD, prolonged and a GAF score of 55 was assigned. A subsequent February 2005 progress note shows similar findings. The Veteran noted that he was doing fairly well but did report that he was not sleeping very well and that he sometimes felt anxious during the day. The diagnostic assessments were PTSD and insomnia and a GAF score of 65 was assigned. A May 2005 Princeton Veteran's Center clinical summary by a treating social worker indicates that the Veteran continued to present with chronic and severe PTSD symptoms. He was noted to exhibit occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood due to such symptoms as anxiety, suicidal and homicidal ideation, disassociation, re-experiencing, panic attacks 6 to 7 times weekly, and chronic major depression with intermittent explosive rage, which affected his ability to function independently, appropriately and effectively. The social worker noted that the Veteran's episodes of anxiety, panic, and anger caused him to manifest a great deal of psychosomatic features. He continued to report great difficulty in adapting to stressful circumstances that resulted in behaviors of avoidance, isolation, paranoia, mistrust and irritability that manifested as explosive rage directed mainly at his wife, family and others around him. He had been unable to establish and maintain effective relationships. He had no friends and relied very heavily on his wife for support and attendance. His sleep hygiene remained poor as he reported nightly bad dreams and nightmares. He was no longer able to work and the major contributing factor was his PTSD, which was considered chronic and severe. The social worker found that the Veteran's current level of functioning was guarded with a GAF score of 40 to 45 and due to the severity of the PTSD symptoms there was minimal improvement expected. A May 2005 private psychiatric evaluation showed that the Veteran reported flashbacks and nightmares about being shot at or stabbed. He had difficulty sleeping and felt tired and irritable most of the time. His appetite had decreased but he did not report any weight gain or loss. He could not tolerate crowds, loud noises or children and preferred to be alone. He had difficulty concentrating and dealing with stress. When he had war-related flashbacks he would cry and experience panic attacks. It was noted that the Veteran usually got up about 5:30 or 6 AM and had difficulty going back to sleep. During the daytime he watched some television, helped with household chores and cut the grass when needed. He would only go out to visit shops for necessities. He used to enjoy hunting and fishing but he was not currently engaging in these activities. He did attend some church services. Mental status examination showed that the Veteran was cooperative but withdrawn. His affect was anxious and depressed. He presented with poverty of thoughts, had difficulty relating to the examiner and his speech revealed frustration. His concentration was impaired and he was only able to name George W. Bush, Bill Clinton, and George Bush, Sr. when asked to name five recent past Presidents of the U.S. From the clinical interview his intellect appeared to be average. His recent and remote memory was fair. His impersonal judgment was intact. He responded to proverbs in an abstract manner and he was able to abstract similarity between the telephone and the pencil. His general fund of knowledge was adequate. He appeared to have a fair amount of insight into his difficulties but a low amount of self-esteem. He did not present with any delusional thinking, ideas of reference or loose associations. The diagnoses were PTSD, neurotic depression, moderately severe and medical problems. The prognosis was poor. The examiner commented that the Veteran had difficulty dealing with stress and that the Veteran's daily activities were limited. The examiner found that the Veteran was not a good candidate for vocational rehabilitation. A June 2005 VA mental hygiene clinic progress note shows that the Veteran stated that he had been feeling more depressed lately. His mother had died about 2 months prior and that had been stressful for him. His sleep was poor. He felt anxious at times. He denied any suicidal or homicidal ideation or any auditory or visual hallucinations. He noted that he spent most of his time at home cutting the grass, working on his computer or reading. He did not have a lot of interest in getting out and doing any other activities. Mental status examination showed predominantly normal findings with insight and judgment into illness noted to be fair. A GAF score of 65 was assigned. An August 2005 VA mental hygiene note shows that the Veteran reported that his mood was bad 50% of the time. He indicated a preference for being alone and reported that he had increased stress with his wife's illness. He had had a recent stress test and his sleep was a little improved with trazadone. He reported nightmares twice a week. He denied any suicidal or homicidal ideation or any auditory or visual hallucinations. Mental status examination produced predominantly normal findings with insight and judgment into illness found to be fair. A GAF score of 65 was assigned. A November 2005 VA mental hygiene clinic note shows that the Veteran reported sleep that was good and bad. He would get about 3 nights of good sleep per week. He had nightmares 2 to 3 times per week. He described his mood as average, better than it used to be. He indicated that he got occasional panic attacks and that he did not trust certain people. He also indicated that he worried a lot about certain things. He did not get really angry but did get upset probably every day. He had learned to walk it off. He was able to feel some enjoyment with church and going out to eat. Mental status examination showed that insight and judgment into illness was fair. Otherwise, the examination was essentially within normal limits. A GAF score of 50 was assigned. A separate November 2005 VA mental hygiene clinic note shows that the Veteran reported that he slept approximately 4 to 5 hours per night. He had nightmares 2 to 3 times per week and noted that he experienced hallucinations in the form of "figures." He also appeared to report hearing voices, although the voices did not speak directly to him. He noted that his appetite and energy level were good. A January 2006 VA mental health note indicates that the Veteran lived with his wife and was an active member of his church. He reported that his appetite was decreased, he was sleeping only 3 to 4 hours per night and his energy level was average. He felt short-tempered, anxious and depressed. He also reported panic attacks 2 to 3 times per week. Additionally, he noted nightmares and flashbacks every night for the past week. Mental status examination showed an anxious mood with a full ranging, appropriate affect. His fund of information was adequate and his thought process was coherent. His intellect appeared above average. Insight and judgment into illness was adequate. Cognitive function and recent, remote and immediate memory appeared intact. The Veteran appeared stable. A February 2006 VA mental hygiene clinic note shows that the Veteran reported that he continued to have poor sleep every other night. He also continued to have nightmares, anxiety, and panic attacks. No current anxiety or stress was noted. A March 2006 VA mental health medication management note shows that the Veteran was noted to still have nightmares 3 to 4 times per week and averaged only four hours of sleep per night. His mood was about the same, he would get irritable and lose his temper once and a while but he reported that he was not as bad as he used to be. His appetite was fair, his energy level was poor, and his activity level was low. He noted intrusive thoughts quite often and he thought that his mood was worse in the winter. The Veteran denied suicidal or homicidal ideation. Mental status examination showed that the Veteran showed no difficulty with concentration or attention. His mood was anxious and his affect was full ranging and appropriate. He maintained good eye contact, smiled and initiated conversation. His fund of information was adequate. His speech was clear, concise, linear and goal directed. His thought process was coherent. His thought content was not psychotic or dangerous. His intellect appeared average and his sensorium appeared clear. Insight and judgment into illness were adequate. Cognitive function appeared intact. Recent, remote and immediate memory also appeared intact. The Veteran appeared stable. The diagnostic assessment was PTSD and a GAF score of 52 was assigned. An August 2008 VA psychologist's note reflects that the Veteran was seen for a home visit. (Records reveal a prior cerebral vascular accident.) He reported current symptoms of flashbacks, avoidance, intrusive thoughts, and a sense of distress when recalling traumatic events from service. There was no hypervigilance or startle response noted. He had physical pain, which was disrupting his sleep cycles. The Veteran did not exhibit any suicidal or homicidal ideation and his memory and judgment were intact. He was frustrated by his capacity limitations. The shift of household management to his wife was very stressful for both of them. The Veteran's wife requested help with heavy cleaning and asked that a bathroom with a shower be installed since the Veteran was unable to go upstairs to bathe. They also inquired about how to put a ramp in the front of the house for entrance since the stairs were steep. The Veteran was receiving 9 hours per week of services for a home health aide who was performing light house work and personal hygiene assistance. On December 3, 2009 VA psychiatric examination, it was noted that the Veteran had not been doing well and had apparently been talking more about his wartime experience. He had been having intrusive thoughts and sleeping problems. He was noted to have multiple medical problems for which he was taking multiple medications. The Veteran reported that he had been thinking about the war more and his wife reported that he would talk about the war all the time and would get upset, with worse instances at night. He reported that he was having flashbacks about people getting killed. The Veteran noted that he was having dreams about the war about every night and that he was getting 5 to 6 hours of sleep per night. He indicated that loud sounds made him jumpy. He also reported mood problems but no suicidal thoughts. The Veteran did not get angry and did not have a problem with anger. He also experienced anxiety about different things but did not experience panic attacks. It was noted that the Veteran's wife was supportive. The examiner noted that the Veteran was unable to do much in terms of daily activities as he had had a past stroke with hemiparesis of the left side. He needed help with dressing, bathing and moving and was unable to feed himself as a result. He also needed help with cleaning and taking his medication. He received in home services for 3 hours, three times a week. His wife helped with cooking at home, taking care of the finances and other household duties. Mental status examination showed that the Veteran had memory problems and would forget things. He reported no audiovisual hallucinations and no suicidal or homicidal thoughts. His immediate recall was 0 out of 3 after five minutes. He was not able to spell the word, "World" backwards. He was able to name objects, repeat language and follow a three stage command. However, he did not want to write a sentence because of his vision problems and he did not want to draw intersecting pentagons. He received a low score of 11 out of 30 on a mini mental status examination but some of the questions he declined to do or did not attempt, making the score invalid. However, he did show problems with concentration and immediate memory problems showing at least mild cognitive impairment. He showed fair insight and judgment. The examiner noted that the Veteran was only competent with management of his VA benefits with the help of his wife. The diagnostic assessment was PTSD and the examiner noted that the Veteran also had multiple medical problems including left hemiparesis, chronic kidney disease, GERD, hypertension, diabetes, history of abdominal aneurysm, benign prostatic hypertrophy, arthritis and chronic heart failure. The examiner assigned a GAF score of 35. The examiner commented that the Veteran's PTSD symptoms had increased as a result of his medical issues and associated mood problems. The examiner found that the Veteran had occupational and social impairment with deficiencies in most areas relating to family relations, mood, thinking etc. The examiner also found that the Veteran had cognitive impairment mostly secondary to his cerebrovascular accident and that the GAF score the examiner assigned was reflective of his Axis I diagnosis. He noted that the Veteran was not employable and that the GAF score was reflective of the severity of the Axis I diagnosis relating to impairment in several areas of mood , thinking, cognition, family relations, work etc. In an October 2009 letter, a friend and fellow service member noted that he was very concerned about the Veteran's physical and emotional health conditions. He indicated that the Veteran had recently started having flashbacks and hallucinations and was unable to control his emotions. This was in addition to all the other physical conditions he was enduring. III. Law and Regulations Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a Veteran. 38 C.F.R. § 4.3. A Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board finds, however, that staged ratings, other than those already assigned, are not warranted here. The 50 percent rating for the Veteran's PTSD has been assigned pursuant to Diagnostic Code 9411. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). When all of 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). IV. Analysis A. Initial rating in excess of 50% prior to December 3, 2009 Prior to December 3, 2009, the Veteran's chronic PTSD symptoms included difficulty sleeping, nightmares, flashbacks, exaggerated startle response, agitation, depressed mood, anxiety, survivor guilt, guardedness, suspiciousness, difficulty concentrating, memory impairment, avoidance of crowds, irritability, intrusive thoughts of past trauma, difficulty dealing with stress, tiredness, poverty of thoughts, low self-esteem and panic attacks as often as two or three times per week. The Board finds that the impairment from this symptomatology was most compatible with assignment of a 50 percent rating for occupational and social impairment with reduced reliability and productivity. In this regard, the Veteran clearly exhibited disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, some level of impaired judgment and memory, difficulty understanding complex commands and difficulty with abstraction. A higher, 70 percent rating is not warranted, as the Veteran was not shown to have the more severe level of symptomatology compatible with occupational and social impairment with deficiencies in most areas. In this regard, the Veteran was not shown to have chronic obsessional rituals interfering with routine activities, speech intermittently illogical, obscure or irrelevant, near continuous panic or depression affecting his ability to function independently, appropriately and effectively, spatial disorientation, neglect of personal hygiene or suicidal ideation. Notably, the Veteran did show some level of irritability. However, it is significant that the evidence does not show that he has ever had any intention to harm anyone. Instead, the evidence indicates that he had learned to "walk it off" when he became very angry. Accordingly, he is not shown to have the severe level of impaired impulse control compatible with a 70 percent rating. Additionally, although the Veteran certainly showed difficulty with relationships, there's no indication that he was more broadly unable to establish and maintain effective relationships. In this regard, he continued to maintain his relationship with his wife despite all of their health difficulties. Further, although the Veteran was shown to exhibit difficulty in adapting to stressful circumstances, given that the other types of chronic symptomatology generally associated with a 70 percent rating were not shown, the Board finds that the overall symptomatology is more compatible with a lower, 50 percent rating. In this regard, the Board finds that although the Veteran's PTSD was shown to result in severe deficiencies in occupational functioning and mood, it was not shown to result in severe deficiencies with family relations, judgment or thinking. 38 C.F.R. § 4.130. The January 2004 and May 2005 Veteran's Center reports do tend to indicate more severe symptomatology than that shown by the VA treatment records and examination reports. These reports suggest that the Veteran was engaging in some level of aggressive and threatening behavior toward family members, that he experienced panic attacks 6 to 7 times weekly and that there were times when he displayed spatial disorientation resulting in a dissociative state and circumstantial and stereotyped speech. However, as the Veteran's Center reports simply constitute general summaries and as the VA treatment records specifically document the Veteran's functioning over time, the Board attaches more weight to the findings presented in the VA treatment records. The Board also notes that the general level of functioning shown in the VA treatment records is generally corroborated by the findings contained in the September 2004 VA examination report. Thus, despite the Veteran's Center findings, the Board finds that the weight of the evidence is against a finding that the Veteran suffered from chronic, near continuous panic, or chronic spatial disorientation resulting in a dissociative state and circumstantial and stereotyped speech, prior to December 3, 2009. The Board also notes that prior to December 3, 2009, the Veteran was assigned GAF scores, which, while predominantly ranging in the 50s and 60s, did also range as low as 40. GAF scores from 31 to 40 tend to indicate 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). Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Thus, a GAF score of 40 could potentially be compatible with the assignment of a higher, 70 percent rating. Notably, however, the Veteran has always been found to at least be on the very high end of this scale. Also, as alluded to above, the weight of the evidence shows that his underlying symptomatology is simply more compatible with the lower, 50 percent rating already assigned. Consequently, despite the assignment of a GAF score as low as 40, a higher 70 percent rating for the Veteran's PTSD is not warranted. See 38 C.F.R. § 4.126(a). B. Rating in excess of 70 percent for PTSD from December 3, 2009 From December 3, 2009, the Veteran's chronic PTSD symptoms have included intrusive thoughts, sleeping problems, flashbacks, nightmares, exaggerated startle response, anxiety, mood problems, significant memory problems, concentration difficulty, mild cognitive impairment and inability to manage his VA benefits. The Board finds that the impairment from this symptomatology is compatible with assignment of no more than a 70 percent rating for occupational and social impairment in most areas. A higher, 100 percent schedular rating, is not warranted as the Veteran is not shown to have gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others or disorientation to time or place; memory loss for names of close relatives, own occupation or own name. In this regard, although the Veteran clearly has significant memory problems, he is not shown to have forgotten the names of close relatives, his prior occupation or his own name. Also, it appears that he is still oriented to time and place. Additionally, although the Veteran does now need assistance with his activities of daily living, it is not shown that this is a result of his PTSD. Instead, it appears to be a result of his stroke and other medical problems. Further, although the Veteran was noted on one prior occasion to have reported seeing "figures" and hearing voices, with the voices not actually speaking to him, there is clearly no indication that he has any persistent delusions or hallucinations due to his PTSD. 38 C.F.R. § 4.130. The Board also notes that from December 3, 2009, a GAF score of 35 has been assigned. As noted above, GAF scores between 31 and 40 tend to indicate 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). Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). While such a score can be compatible with the assignment of a 70 percent rating (i.e. for occupational and social impairment with deficiencies in most areas), it is not compatible with assignment of a higher, 100 percent schedular rating for total occupational and social impairment. Also, more generally, while the Veteran may be shown to have total occupational impairment due to his PTSD, he is not shown to have total social impairment as a result of it. In this regard, although he has been subject to numerous health challenges, he has still been able to continue living with his wife and has also been able to accept assistance from in-home caregivers. Accordingly, in the absence of total social impairment, the Board finds that the criteria for the assignment of a 100 percent rating for PTSD have not been met. Also, as noted, he has been found entitled to a total rating for individual unemployability largely secondary to the PTSD. C. Extraschedular consideration for both rating periods The Board has also considered whether the Veteran's claim for increase should be referred for consideration of an extraschedular evaluation, and has concluded that no such referral is warranted for the time frame either prior to, or from, December 3, 2009. As explained above, the Veteran's symptomatology is fully contemplated by the pertinent diagnostic criteria. There is nothing in the record to suggest that his disability picture is so exceptional or unusual as to render impractical the application of the regular schedular standards. See, e.g., Thun v. Peake, 22 Vet. App. 111 (2008). ORDER An initial rating in excess of 50 percent for PTSD prior to December 3, 2009 is denied. A schedular rating in excess of 70 percent for PTSD from December 3, 2009 is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs