Citation Nr: 1128434 Decision Date: 07/29/11 Archive Date: 08/04/11 DOCKET NO. 05-37 258 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to April 13, 2011. 2. Entitlement to an initial, staged evaluation in excess of 70 percent for PTSD from April 13, 2011. REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The appellant had active service from February 1970 to October 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska, that, in pertinent part, granted service connection for PTSD and assigned a 30 percent initial evaluation, effective January 20, 2005. This case was previously before the Board in March 2008, at which time the Board denied the appellant's claim for entitlement to an initial evaluation in excess of 30 percent for PTSD. In an April 2010 Memorandum Decision, with Judgment entered May 2010, the United States Court of Appeals for Veterans Claims (Court) vacated, in pertinent part, that portion of the March 2008 Board decision which denied entitlement to a higher initial evaluation for PTSD, and remanded the issue to the Board for readjudication in accordance with the directives in the Court's decision. In January 2011, the Board remanded the issue of entitlement to an initial evaluation in excess of 30 percent for PTSD to the RO for additional development. For the reasons discussed below, the Board finds that the RO substantially complied with the mandates of the January 2011 remand and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). A RO Decision Review Officer's decision, in a May 2011 supplemental statement of the case, granted a higher, staged, initial evaluation of 70 percent for PTSD, from April 13, 2011. The Court has held that a "decision awarding a higher rating, but less than the maximum available benefit . . . does not . . . abrogate the pending appeal . . . ." AB v. Brown, 6 Vet. App. 35, 38 (1993). Thus, the Board will proceed to adjudicate the appeal. FINDINGS OF FACT 1. From January 20, 2005, through April 12, 2011, the appellant's service-connected PTSD was manifested by difficulty in establishing and maintaining effective work and social relationships, sleep disturbance, depression, and occasional suicidal ideation, productive of occupational and social impairment comparable to no more than reduced reliability and productivity. 2. From April 13, 2011, the appellant's service-connected PTSD is manifested by anxiety, nightmares, panic attacks, hyperarousal symptoms, and irritability, productive of occupational and social impairment comparable to no more than deficiencies in most areas such as work, school, family relations, judgment, thinking or mood. CONCLUSIONS OF LAW 1. For the period from January 20, 2005, through April 12, 2011, the criteria for entitlement to an initial, staged evaluation of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2010). 2. From April 13, 2011, the criteria for entitlement to an initial, staged evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the appellant's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. 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 appellant 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 appellant). 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 claimant. 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 appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions as to the appellant's claims. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2010). The United States Court of Appeals for Veterans Claims (Court) held that VA 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Court observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006); see also 38 U.S.C.A. § 5103(a). Because the July 2005 rating decision granted the appellant's claim for service connection for PTSD, such claim is now substantiated. His filing of a notice of disagreement as to the July 2005 rating decision does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3) (2010). Rather, the appellant's appeal as to the initial rating assignment here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the appellant of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here, as will be discussed below. The October 2005 statement of the case (SOC), under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic code (DC) for rating the disability at issue (38 C.F.R. § 4.130, DC 9411), and included a description of the rating formulas for all possible schedular ratings under this diagnostic code. The appellant was thus informed of what was needed not only to achieve the next-higher schedular rating, but also to obtain all schedular ratings above that assigned. Therefore, the Board finds that the appellant has been informed of what was necessary to achieve a higher rating for the service-connected disability at issue. Duty to Assist The Board concludes VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file, in compliance with the January 2011 Board remand. Private medical records identified by the appellant have been obtained, to the extent possible. The appellant has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the appellant. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the appellant's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2010). The RO provided the Veteran appropriate VA examinations in May 2005, August 2005, and April 2011. The examinations is adequate because they are based on thorough examinations, a description of the appellant's pertinent medical history, and a complete review of the claims folder. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The appellant has not reported receiving any recent treatment specifically for this condition and there are no records suggesting an increase in disability has occurred as compared to the April 2011 VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the appellant's service-connected disorders since he was last examined in April 2011. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The May 2005, August 2005, and April 2011 VA examination reports are thorough and supported by VA treatment records and provided findings pertinent to the rating criteria. The examinations in this case are adequate upon which to base a decision. 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). II. Legal Criteria Ratings in General Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2009). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the appellant. Id. § 4.3. An appeal from the initial assignment of a disability rating, such as the appeals in this case, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating Criteria for PTSD PTSD is rated by applying the criteria in 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). The VA Schedule rating formula for mental disorders reads in pertinent part as follows: 100 percent rating (the maximum schedular rating) - Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 70 percent - 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. 50 percent - 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 effective work and social relationships. 30 percent - 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, recent events). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). 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. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The appellant's medical records reflect nonservice-connected Axis I diagnoses of panic disorder and depression, not otherwise specified. See May 2005 and April 2011 VA examination reports. However, most of the medical records have not specifically indicated what symptoms are attributable only to the nonservice-connected disability. The May 2005 VA examination report reflects that the appellant's panic disorder is a separate diagnosis and independent of the PTSD diagnosis. The VA examiner opined that PTSD did not cause the panic disorder and the PTSD has not aggravated the panic disorder. However, the April 2011 VA examiner opined that at this point, the appellant's panic disorder, in partial remission, and depression, not otherwise specified are so intertwined with the symptoms of PTSD that it is not possible to separate them out without resorting to speculation. Consequently, from April 2011, the Board will, for the limited purpose of this decision, attribute all psychiatric signs and symptoms to his service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998) (finding that when it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102, which requires that reasonable doubt on any issue be resolved in the veteran's favor, clearly dictates that such signs and symptoms be attributed to the service-connected condition). Prior to April 2011, as the May 2005 VA examiner indicated that the appellant's non-service connected panic disorder was separate from PTSD, the Board will not attribute the appellant's signs and symptoms due to his non-service-connected panic disorder to his service-connected PTSD. Global Assessment of Functioning (GAF) GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)) (DSM-IV). According to DSM-IV, a GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. A GAF score of 31 to 40 indicates the examinee has some impairment in reality testing or communication or major impairment in several areas, such as work or school. A GAF score of 21 to 30 indicates that the examinee's behavior is considerably influenced by delusions or hallucinations, has serious impairment in communication or judgment, or is unable to function in almost all areas of life. See also QUICK REFERENCE TO THE DIAGNOSTIC CRITERIA FROM DSM-IV, 46-47 (1994). III. Analysis January 20, 2005, through April 12, 2011 As noted above, a July 2005 rating decision granted entitlement to service connection for PTSD with an evaluation of 30 percent effective January 20, 2005. Thus, the period on appeal for the issue of entitlement to an initial evaluation in excess of 30 percent is from January 20, 2005. 38 C.F.R. § 3.400(o)(2) (2010). The appellant contends that he is entitled to an evaluation in excess of 30 percent for PTSD. After reviewing the evidence of record, the Board finds that a 50 percent rating is warranted for the period from January 20, 2005, through April 12, 2011. The evidence indicates that the appellant had occupational and social impairment with reduced reliability and productivity. The evidence reflects that the appellant's speech was circumstantial during the period on appeal and that he had impaired abstract thinking. In an August 2005 VA examination, the appellant's speech was spontaneous, rapid, clear, and often pressured. However, the August 2005 VA examiner noted that the appellant's thought process was rambling, pressured, and demonstrated circumstantiality. The appellant repeated himself often and appeared to get disorganized at times. There was no expansiveness. The examiner noted that it was hard to get him to answer questions. He would start and then begin repeating unrelated information about his condition. The information was a repeat of what he had already said, it took persistence to get him to answer a question. The VA examiner noted that it was hard to reason with him and discuss options that he might have. He presented most of the issues in a black and white way. The VA examiner also noted that the appellant demonstrated preoccupation with one or two topics and ruminations. The appellant dramatically stuck on a topic that he repeated a number of times. The August 2005 VA examiner also noted that the appellant's affect was inappropriate and labile. He went from loud voice and dramatic presentation to how important his medications were to him to tears over his concerns about his condition. His mood was anxious, agitated, fearful and dysphoric. In contrast, a May 2005 VA examination report reflects that the appellant's speech was unremarkable and that his thought process was logical, goal directed, and coherent, and his thought content unremarkable. September 2008, December 2008, April 2009 and June 2009 VA treatment records note that the appellant's speech was relevant and spontaneous. March 2009, December 2009 and June 2010 VA treatment records indicate that the appellant's speech was pressured. A December 2010 VA treatment record reflects that the appellant's speech was abrupt. The December 2009 VA treatment record noted that the appellant's thought processes were logical and goal-directed, but his thought content was significant for grandiosity. The June 2010 VA treatment record indicates that the appellant's thought processes were notable for flight of ideas and his thought content was significant for grandiosity. His insight was fair. Although the evidence indicates that appellant's speech and thought processes were normal at times during the period on appeal, it also indicates he had periods of circumstantial speech and impaired abstract thinking throughout the period on appeal. The evidence reflects that the appellant reported problems with his short and long-term memory. The May 2005 VA examiner noted that the appellant's remote memory, recent memory and immediate memory were normal, and specifically noted that he had an excellent memory. The August 2005 VA examination report reflects that the appellant's memory was normal. However, a March 2005 VA treatment record reflects that the appellant had profound amnesia for most of the events during his Vietnam tour. Additionally, in a December 2005 statement, the appellant reported that he had a terrible memory for short time periods. He stated that he would walk around the farm, and go to get something then forget when he went to get or do. He stated that he had a list on his refrigerator of 50 things to do, and that he cannot remember to do certain things if they are not on his list. He reported that it was impossible for him to stay focused. The appellant is competent to report the symptoms he experiences. Thus, the evidence indicates the appellant had some impairment of short-and long-term memory. There is no evidence the appellant had difficulty in understanding complex commands. The May 2005 VA examination report reflects that the appellant's attention was intact, that he was able to do serial 7's, and that he could spell a word forward and backwards. He was intact to person, time and place. His judgment was intact and his intelligence was above average. The evidence reflects that the appellant experienced frequent panic attacks. The May 2005 VA examination report indicates the appellant reported daily panic attacks for which he took two benzodiazepines, which he carried with him at all times. The August 2005 VA examination report reflects that the appellant reported 150 panic attacks a month. The May 2005 VA examiner noted that the appellant's panic attack symptoms met the criteria for panic disorder, which the VA examiner could not connect to active duty. The VA examiner noted that the appellant's panic attacks caused extreme anxiety and had caused agoraphobia in the past. The VA examiner noted that the symptoms were so severe that the appellant quit farming from 1996 to 2000. As noted above, the May 2005 VA examiner found that the appellant's panic disorder was a separate diagnosis from his PTSD and that the two diagnoses were independent of each other. Thus, although the appellant had severe panic attack symptoms, as the symptoms were attributed to his panic disorder prior to the April 2011 VA examination, the symptoms are not relevant to the issue of whether the appellant is entitled to an evaluation in excess of 30 percent for PTSD. The appellant has demonstrated difficulty in establishing and maintaining effective work and social relationships. The March 2005 VA treatment record noted that the appellant had been very isolated socially and even from his kids. The May 2005 VA examiner noted that the appellant's PTSD has not caused him to miss work, although he has missed work due to his panic disorder in the past. The VA examiner found that PTSD resulted in mild or transient decreased efficiency, productivity, and reliability only during periods of stress. The VA examiner also found that the appellant had a mild or transient inability to perform work tasks only during periods of stress. The appellant had occasional impaired work, family and other relationships, of moderate severity. A September 2005 VA treatment record notes that the appellant reported that he harvests solo and does not get help for the harvest because he did not want to work with anyone. He also reported that he took frequent breaks because of his anxiety. A May 2005 private treatment record from J.G., M.D., reflects that the appellant got along well with his wife and that he occasionally acted out just to cover up his inner problems. The evidence reflects that many of the appellant's problems with his ability to work were related to anxiety episodes. In the March 2006 statement, the appellant reported that he was unable to farm at times due to anxiety episodes. A July 2005 VA treatment record reflects that the appellant reported that he could only stay out in the field on a tractor for a couple of hours. Then, his anxiety would rise, and he would go in the house, take a pill and lie down. He reported that when his anxiety diminished, he would return for another one or two hour stint. In an October 2005 statement, the appellant reported that he had to quit farming for four years because he was unable to work. He stated that he was passing out and unable to operate machinery. As noted above, the appellant's panic attacks were attributed to his non-service-connected panic disorder by the May 2005 VA examiner. The May 2005 VA examiner specifically noted that the appellant's work was affected by his panic disorder. However, the evidence also reflects that the appellant's PTSD has also affected his ability to work because of his avoidance of other people. In the December 2005 letter, the appellant stated that he chose farming because he could work by himself. He stated that he did not work well with other people and that he was by himself 90 percent of the time. He stated that he had constant nightmares which terrified his wife, children and grandchildren. He also reported experiencing flashbacks. He stated that his mood changed constantly. He stated that he became volatile when he had to associate with people. The March 2005 VA treatment record reflects that the appellant was easily angered and was stressed by even the most simple situations, which led to his almost total dependence upon his wife to accomplish everything, but the farming, which he attacked in a driven "workaholic" fashion. Although that appellant reported suicidal ideation at times during the period on appeal, he also consistently denied homicidal and suicidal ideation. The May 2005 VA examination report reflects that the appellant did not have suicidal or homicidal thoughts. The August 2005 VA examination report also indicated the appellant did not have suicidal or homicidal thoughts. In contrast, in a January 2005 claim, the appellant reported that he experienced suicidal thoughts. In an August 2005 letter, the appellant's representative also asserted that the appellant had suicidal ideation. The representative stated that the appellant's wife reported that the appellant had considered suicide. In a statement received in December 2005, the appellant reported that he has suicidal ideas all the time. In a March 2006 statement, the appellant stated that "living your life wanting to die to put all the terrible memories behind you is no way to live." In contrast, VA treatment records dated in September 2008, December 2008, April 2009, June 2009, June 2010, and December 2010 reflect that the appellant did not have suicidal or homicidal ideation. Thus, the evidence of record contains conflicting evidence regarding whether the appellant experienced suicidal ideation. The May 2005 VA examiner found that the appellant had a GAF for PTSD of 55 and a GAF score of 50 for panic disorder, with an overall score of 55. December 2009 and June 2010 VA treatment records reflect that the appellant had a GAF score of 60. As noted above, a GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. Based upon the above evidence, the Board finds that a 50 percent evaluation is warranted for the appellant's service-connected PTSD, for the period from January 20, 2005, through April 12, 2011. As discussed above, the appellant had occupational and social impairment with reduced reliability and productivity. The appellant had symptoms of circumstantial speech, reported problems with short- and long-term memory, had symptoms of impaired abstract thinking, reported disturbances of motivation and mood, and had difficulty in establishing and maintaining effective work and social relationships. Moreover the appellant had GAF scores of 55 and 60, indicating moderate difficulty in social or occupational functioning due to PTSD. The Board recognizes that the veteran's PTSD symptomatology has not demonstrated all the criteria for a 50 percent rating. However, as stated in 38 C.F.R. § 4.21, it is not expected that every single symptom within a set of diagnostic criteria be exhibited. The appellant's panic attacks were attributed to his panic disorder, and he did not have a flattened affect or demonstrate difficulty in understanding complex commands. Nevertheless, with resolution of any doubt in favor of the appellant, the Board finds the appellant's overall disability picture is more nearly approximated by a 50 percent rating for the period from January 20, 2005, through April 12, 2011. 38 C.F.R. §§ 4.3 and 4.7. As noted above, to achieve the next-higher 70 percent rating under Diagnostic Code 9411, the evidence must show 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. The Board finds that the overall weight of the evidence fails to reveal occupational and social impairment of such severity as to allow for a finding that the appellant's disability picture from January 20, 2005, through April 12, 2011, was more analogous to the next-higher 70 percent rating under Diagnostic Code 9411. There was no evidence of obsessional rituals which interfered with routine activities. Although the appellant's speech was pressured and circumstantial during the period on appeal, it was not intermittently illogical, obscure or irrelevant. The appellant did not have symptoms of near continuous panic or depression affecting the ability to function independently. The appellant was able to work full time as a self-employed farmer throughout the period on appeal. There was also no evidence of impaired impulse control, spatial disorientation, or neglect of personal hygiene in the appellant's VA examination reports or VA treatment records. Although the appellant reported that he had difficulty in establishing and maintaining effective relationships, the evidence did not establish an inability to establish and maintain effective relationships. The appellant reported regularly seeing his family and had been with his wife since high school. (See December 2008 VA treatment record). He also reported that he sang Karaoke to make additional income. (See May 2005 VA examination report and September 2008 VA treatment record). As discussed above, the evidence reflects that the appellant reported suicidal ideation during the period on appeal. However, VA examination reports and VA treatment records reflect that he also consistently denied having suicidal and homicidal ideation. Moreover, the appellant did not have any other symptoms of a 70 percent disability rating from January 20, 2005, through April 12, 2011. His GAF scores of 55 and 60 are consistent with no more than moderate difficulty in social and occupational functioning. The Board finds that the overall evidence from January 20, 2005, through April 12, 2011, indicates the appellant had moderate symptoms of PTSD, but it does not indicate that he had occupational and social impairment with deficiencies in most areas. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, except where in contrast to objective clinical findings, the reported symptoms are consistent with a rating of 50 percent disabling. The Board finds that the evidence of record does not show distinct time periods exhibiting symptoms warranting staged evaluations from January 20, 2005, through April 12, 2011. Fenderson, 12 Vet. App. at 126; Hart, 21 Vet. App. at 509-10. The May 2005 and August 2005 VA examination reports and VA treatment records reflect that the appellant had similar symptoms throughout the rating period on appeal. In sum, the weight of the available evidence demonstrates that the appellant's service-connected PTSD has warranted a 50 percent rating, but no higher, for the period from January 20, 2005, through April 12, 2011. From April 13, 2011 As noted above, a Decision Review Officer granted entitlement to a 70 percent evaluation for PTSD from April 13, 2011, in a May 2011 supplemental statement of the case and rating decision. The Board has reviewed the evidence of record and finds that it does not support an evaluation in excess of the 70 percent currently assigned, from April 13, 2011. The Board notes that the competent evidence does not demonstrate gross impairment in thought processes or communication. The April 2011 VA examination report reflects the appellant's speech was spontaneous, clear and coherent. His thought processes had rambling and circumstantiality. However, his thought content was unremarkable, he had no delusions and he understood the outcome of his behavior. The VA examiner noted that much of the appellant's thinking is consumed with worrying and ruminating, but he is logical and can make decisions. Thus, although he demonstrated some deficiencies in his thought processes, it did not rise to the level of gross impairment in thought processes or communication. The competent medical evidence also fails to demonstrate an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The April 2011 VA examiner noted that the appellant was clean and appropriately dressed. He noted that the appellant was able to maintain minimum personal hygiene and there was no problem with activities of daily living. The evidence of record also fails to reveal disorientation to time or place or memory loss for names of close relatives, own occupation or own name. Indeed, upon mental status examination in April 2011, the appellant was intact as to person, time and place. The report also reflects that his memory, including remote, recent and immediate memory, was normal. The evidence of record further fails to reveal grossly inappropriate behavior or show that the appellant was a persistent danger to himself or others. The appellant denied the presence of homicidal and suicidal thoughts at the April 2011 VA examination. The examiner noted that the appellant's extent of impulse control was good and there were no episodes of violence. The VA examination report reflects that the appellant reported that he was quickly irritated and at times got loud. His wife explained that at times he would shout, but it had not gone to the point of throwing property or being assaultive. The April 2011 VA examination report reflects that the appellant did not have obsessive/ritualistic or inappropriate behavior. The evidence also fails to establish persistent delusions or hallucinations. The April 2011 VA examination report indicates that the appellant did not have delusions. The evidence does indicate serious symptoms, including depression, nightmares, intrusive thoughts, increased arousal, hypervigilance, irritability, and difficulty concentrating. At the time of the April 2011 VA examination, the appellant and his wife were about to celebrate thirty-nine years of marriage. The appellant reported that he is socially isolated and seldom sees his mother, children or grandchildren. The appellant is self-employed as a farmer. The April 2011 VA examiner noted that the appellant continues to farm 550 acres of land. The appellant reported estimating a thousand hours of not being able to work due to his PTSD, but since he is self-employed, he reported that he has been able to successfully manage the farm on his own. He reported that he did not hire anyone to help him because he cannot get along with people. He had no recreational activities or hobbies. His wife told the April 2011 VA examiner that work was his only interest. The appellant reported that he tried to play golf three times last year and did not plan to go this year. The April 2011 VA examiner found that there was not total occupational and social impairment due to PTSD signs and symptoms. However, the appellant's PTSD has affected his family relations. His wife noted that it had been a challenge to maintain a relationship because of his irritability and isolation. The VA examiner also noted that the appellant could not work for somebody else, but he can work for himself because of the flexibility. When he does not feel like working, the appellant takes time off and makes up for that time off by working longer hours, and is thus, able to maintain his farm operation. The Board finds that the overall weight of the evidence fails to reveal a disability picture most nearly approximated by the next-higher 100 percent evaluation for PTSD under Diagnostic Code 9411. In so finding, the Board acknowledges a GAF (Global Assessment of Functioning) score of 52 assigned upon VA examination in April 2011. As noted above, a GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Board finds that a GAF score of 52, indicating moderate symptoms of PTSD, supports the currently assigned 70 percent evaluation, from April 13, 2011. Based on the foregoing, the Board concludes that the appellant's disability picture does not most nearly approximate the next-higher 100 percent rating under Diagnostic Code 9411, from April 13, 2011. The April 2011 VA examination report reflects that the appellant has moderate symptoms of PTSD, including impaired impulse control, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. His symptoms cause occupational and social impairment with deficiencies in most areas. However, the appellant is still able to farm 550 acres of farmland by himself and has been married for thirty-nine years. The evidence does not demonstrate total occupational and social impairment. The appellant is able to perform activities of daily living, including maintenance of minimal personal hygiene, and denied suicidal and homicidal ideation. His memory is normal and he did not have obsessive or ritualistic behavior. In conclusion, the Board finds that the currently assigned 70 percent rating for PTSD, from April 13, 2011, appropriately reflects the appellant's disability picture from April 13, 2011. IV. Extraschedular The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet.App. 111, 115 (2008). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet.App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the appellant's PTSD with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the appellant's disability level and symptomatology during the period on appeal. Further, the appellant has not alleged that the schedular evaluation is inadequate. Therefore, the available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, 22 Vet.App. at 115. TDIU is an element of all appeals for an increased evaluation. Rice v. Shinseki, 22 Vet. App. 447 (2010). In this case, however, TDIU consideration is not warranted. The appellant has not contended and the evidence does not indicate that the appellant is unemployable as a result of his PTSD. The April 2011 VA examination report reflects that the appellant has worked full time as a self-employed farmer throughout the rating period on appeal. Although the appellant told the April 2011 VA examiner that he did not work for a four year time period in the 1990s, this period was prior to the rating period on appeal. ORDER Entitlement to an initial, staged evaluation of 50 percent for PTSD, for the period from January 20, 2005, through April 12, 2011, is granted. Entitlement to an initial, staged evaluation in excess of 70 percent for PTSD from April 13, 2011, is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs