Citation Nr: 1114976 Decision Date: 04/15/11 Archive Date: 04/21/11 DOCKET NO. 06-15 562 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut THE ISSUE Entitlement to ratings in excess of 30 percent prior to May 7, 2010, and in excess of 50 percent from that date for the service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Bredehorst INTRODUCTION The Veteran served on active duty from January 1970 to January 1972. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a December 2004 rating decision that denied a rating in excess of 30 percent for the service-connected PTSD. In August 2006, the Veteran requested a hearing before a Decision Review Officer (DRO); however, the request was subsequently withdrawn in January 2007. In June 2009, the Board remanded the case to the RO for additional development of the record. In a December 2010 rating decision, the RO increased the rating to 50 percent for the service-connected PTSD, effective on May 7, 2010. Since the Veteran did not express satisfaction with the rating, the matter remained in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). The issue of a total rating based on unemployability by reason of service-connected disability (TDIU) has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction and refers the matter to the attention of the AOJ for appropriate action. FINDING OF FACT Throughout the appeal period, the clinical signs and manifestations of the service-connected PTSD more nearly approximate a disability picture manifested by occupational and social impairment, with deficiencies in most areas, such as work, family relations, thinking and mood due to symptoms of social avoidance, isolation, intrusive memories, flashbacks, nightmares, insomnia, hypervigilance, exaggerated startle responses, anxiety, depressed mood, irritability, poor impulse control, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships; total occupational and social impairment is not demonstrated. CONCLUSION OF LAW The criteria for the assignment of a rating of 70 percent, but no more, for the service-connected PTSD have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.3, 4.7, 4.130 including Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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. 38 C.F.R. § 3.159(b)(1) (including as amended effective May 30, 2008, 73 Fed. Reg. 23353 (Apr. 30, 2008)). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that the notice requirements of the VCAA applied to all 5 elements of a service connection claim (i.e., to include the rating assigned and the effective date of award). The September 2004 and November 2009 letters provided the Veteran with notice of VA's duties to notify and assist him in the development of his claim consistent with the laws and regulations outlined above. In this regard, the letters informed him of the evidence and information necessary to substantiate his claim, the information required of him to enable VA to obtain evidence in support of his claim, and the assistance that VA would provide to obtain information and evidence in support of his claim. He was also given general notice regarding how disability ratings are assigned, disability ratings, and effective dates of awards. Although complete notice was not provided prior to the initial adjudication of the claim, which constitutes a notice timing defect, this matter was readjudicated by a December 2010 Supplemental Statement of the Case (SSOC), which cured the defect. See 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006); see also See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a statement of the case (SOC) or SSOC, is sufficient to cure a timing defect). The Board also finds that VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A (West 2002). The Veteran's service treatment records have been associated with his claims file, and VA has obtained all pertinent/identified records that could be obtained. The RO arranged for VA examinations. These examinations are deemed adequate for rating purposes. Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, VA's duty is met. Legal Criteria and Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2010). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating criteria for rating mental disorders read as follows: A 100 percent rating requires 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. A 70 percent rating requires 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 50 percent rating requires 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. A 30 percent rating requires 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). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). The Court has held that GAF scores are 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); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p. 32). GAF scores ranging between 61 to 70 reflect 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, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect 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). Scores ranging from 31 to 40 reflect some impairment in reality testing or communications (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). Scores ranging from 21 to 30 are indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Id. An examiner's classification of the level of psychiatric impairment, by words or by a score, is to be considered, but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. A GAF score, however, is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. Massey v. Brown, 7 Vet. App. 204, 207 (1994). Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C.A. § 7104(a). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. The Board notes that from April 1, 2005 to May 1, 2005 and from December 15, 2008 to March 31, 2009, total temporary ratings were assigned due to hospitalization in excess of 21 days pursuant to 38 C.F.R. § 4.29 (2010). In the present case, the service-connected PTSD was assigned staged ratings with a 30 percent in effect prior to May 7, 2010 and a 50 percent rating beginning on that date. The VA treatment records in March 2004 indicate the Veteran sought treatment for heroin abuse. He reported that his main trigger for using drugs was to self medicate his symptoms of PTSD. The Veteran reported having constant flashbacks, anxiety and depression. He was also highly sensitive to the sound of helicopters. He denied having any prior treatment for PTSD and of having a history of violence or assaulting others. The mental status evaluation reveals nothing unusual in his thought content or process. His judgment was impaired, his insight was limited, and his mood was anxious. He had a history of impulsivity and substance abuse, but he had no suicidal or violent ideation. There were no perceptual disturbances such as hallucinations. A GAF score of 45 was assigned. A June 2004 psychiatric evaluation reported that the Veteran had a history of opioid dependence in partial remission, nicotine dependence and possible PTSD. There was no evidence of psychosis or a history of prior psychiatric admissions. The Veteran appeared well groomed. The rate, rhythm, and tone of his speech were normal. No psychomotor agitation was noted, and his mood was described as "fine." His affect was appropriate; thought process was clear and coherent; and thought content was clear of delusions, suicidal/homicidal ideation, and audio or visual hallucinations. It was noted that the Veteran was beginning hepatitis C therapy with interferon that involved neuropsychiatric side effects and that, if his the PTSD symptoms worsened while on this medication, he was willing to try psychotropic medications. He was not an imminent danger to self or others. A GAF score of 50 was assigned. That same month the Veteran was screened for PRRP and met the minimum requirements for admission to the program. The social worker noted that the Veteran had more difficulty managing his PTSD symptoms (nightmares, flashbacks, anger, and poor sleep) now that he was not "self-medicating." A May 2005 VA treatment record indicated the Veteran remained angry and frustrated over being terminated from the PRRP program; however, he did not bolt, run or use drugs. On May 2005 VA examination, the examiner noted that the Veteran had had two prior VA examinations that described chronic PTSD symptoms related to service as well as chronic and severe opioid dependence. The GAF scores at those times were dramatically different despite the relative similarity in the description of his symptoms (a GAF score of 70 in 1994 vs. a GAF score of 45 in 2001). The VA examiner noted that the Veteran was discharged from a PRRP residential rehabilitation program a few weeks earlier due to difficulty adjusting, problems following guidelines, and interpersonal issues. He also noted there were GAF scores of 45 and 50 since March 2004. The current evaluation revealed the Veteran endorsed occasional nightmares, mild distress and reactivity in response to things that reminded him of Vietnam, chronic sleep difficulties that resulted in 4 to 5 hours of sleep per night, hypervigilance, and claustrophobia. The Veteran reported that he could not tolerate movie theaters, but could go to stores or to the mall if they were not crowded. He made some efforts to suppress thoughts and feelings related to Vietnam and the examiner noted that the Veteran used heroin extensively over the years to avoid and suppress thoughts and feelings in general, to avoid people, and to disconnect from others. The Veteran indicated that his symptoms were aggravated once he had been clean from heroin for the past 2 years. His psychosocial history indicated that he had legal trouble and had been incarcerated at times in the past for crimes related to supporting his drug addiction. The Veteran was currently unemployed, but planned to work as a painter part-time starting in next month. The Veteran had a history of multiple drug detoxification and rehabilitation programs in the past with only a recent one-month treatment program for PTSD that ended in the previous month. His description of his interactions with PRRP staff and Vet Center staff indicated that he had difficulties with authority and taking direction. On the mental status examination, the Veteran was dressed casually and presented as friendly and cooperative, but with an element of defensiveness. His affect was positive with no negative display. Thought processes were logical and organized with no evidence of a thought disorder. There was no suicidal or homicidal ideation. Cognition was grossly intact. His insight was fair to good and his judgment was good but with a history of impulsiveness. The examiner noted that the current GAF score was 55 and that this was also the highest score for the past year. He summarized that the Veteran had chronic symptoms of PTSD in the mild to moderate range. There was no clear evidence of distress on the current examination. The Veteran suffered with chronic maladjustment, which was due in part to his chronic opioid dependence and related legal difficulties, although his PTSD also at least as likely as not contributed in large to his difficulties. Symptoms specifically attributed to PTSD caused some impairment with successful adaptation in a structured inpatient treatment program. The June 2005 VA treatment records showed no changes in his speech or thought content. There continued to be no suicidal or homicidal ideation or audio or visual hallucinations. Although he denied hearing voices, he did report that he heard people screaming and that this was related to Vietnam. His insight and judgment varied from adequate to limited. In addition to the PTSD symptoms already noted, he had anxiety and irritability. He felt mildly depressed after being discharged from PRRP program. Although feeling angry about PRRP, he had no desire to hurt anyone. He recently relapsed into alcohol and heroin abuse. A GAF score of 30 was assigned. An April 2006 VA intake note indicates the Veteran was interested in a day program for drug treatment. He continued to have flashbacks, nightmares and difficulties with authority figures due to his PTSD. His GAF score was 45. A psychiatric evaluation noted that he was sober and had not used heroin in six months. He complained of restless sleep secondary to feeling in "survival mode," mild anxiety and restlessness in crowded places such as stores and in closed places. His mood and energy levels were good. He had some nightmares and was hypervigilant, but continued to deny hallucinations, or suicidal or homicidal ideation. The mental status evaluation indicates there was no change in his speech, thought process or thought content. He was cooperative and euthymic, but slightly anxious. His appearance was slightly disheveled. His insight was limited, and his judgment was impulsive. The Veteran's memory appeared intact. He was not considered a danger to self or others. His anxiety and PTSD put him at risk for using drugs to control his symptoms. A GAF score of 40-45 was assigned. The April 2006 VA treatment records also indicated that the Veteran was at risk for using drugs to control his PTSD and anxiety symptoms. The SADP program records note that he rarely socialized and communicated easily and that his motivation was self-directed. He had interests in multiple activities, and his current activity was working out. The Veteran was not on any medication for his PTSD and endorsed some vigilance and discomfort in closed areas, but there were no current active nightmares, flashbacks or marked numbing. He reported experiencing psychological or emotional problems on 10 out of the past 30 days. He complained of experiencing serious anxiety or tension and trouble understanding, concentrating and remembering. A July 2006 psychiatric consultation showed that the Veteran's main complaint was insomnia due to nightmares related to his PTSD. His moods varied from good to irritated, and his irritability was due to his anxiety. He also reported becoming isolative to avoid confrontations. He continued to experience other symptoms previously reported. The mental status examination indicated he was cooperative and reasonable; his appearance was appropriate, and his speech was normal. His affect was congruent with his euthymic mood, thought process and content were normal, and his memory was intact. He continued to have no homicidal or violent ideation and he was no significant risk to self or others. His judgment was limited. His drug dependence was considered to be in early remission, and he was given a GAF score of 45. The August and October 2006 VA treatment records do not reflect any significant changes in his symptoms. The April 2008 VA records indicate the Veteran was seeking a residential rehabilitation treatment program to get sober. He had recently been released from jail after being in prison from December 2006 to March 2008 due to a parole violation. Immediately after his release, he relapsed into drug use. A mental status examination was unremarkable for alertness, orientation, memory, speech, affect, mood, psychosis, judgment and insight. He was given a GAF score of 45. The treatment notes in May 2008 showed that he was psychiatrically stable at baseline and had no new complaints. He was alert, appropriately dressed, groomed, and cooperative. His speech, thought processes, and thought content were normal. His mood was euthymic with a congruent affect. His judgment and insight were fair, and his memory was intact. A July 2008 VA mental health note indicated that the Veteran had a verbal dispute with another resident at the living facility and that this was the second time this had occurred. The matter was resolved that night with no further negative interactions between the two. A September 2008 VA record indicated that the recent events resulted in a worsening of the Veteran's symptoms. He was not able to sleep at all, was hypersensitive, avoided contact with others, and was easily angered and hyperaroused. Due to his symptoms, the Veteran was afraid that he might "lose it." In October 2008, there was a discussion about his concern that other residents had concerning the Veteran's behavior and temper. The May 2009 VA mental health records indicate the Veteran was recently discharged after completing a PRRP program in March 2009 and relapsed into drug use the following month. The Veteran reported that his PTSD symptoms had flared up since he was in the PRRP program. During an assessment screening, he was somnolent, but able to engage in the interview. The mental status examination indicated he was adequately groomed and showed a full range of affect with normal intensity. He was not labile or inappropriate. His thought process was linear, and he denied having suicidal or homicidal ideation, flashbacks or hallucinations. His insight and judgment were fair. He was at low risk for suicide or violence. A May 2009 VA screening note indicated that the Veteran was seeking admission to a psychosocial residential rehabilitation treatment program in order to "get clean." He reported some vague suicidal ideation while "dope sick" a few weeks earlier, but denied having any plans and expressed feelings of hope. He was not considered a danger to self or others, and the risk of violence was low. He was considered eligible to participate in PRRTP. He was given a GAF score of 30. A psychiatric evaluation on the following day indicated that one of the consequences of the Veteran's drug use was a worsening of his PTSD. The Veteran reported that antecedents to drug use included a buildup of stress and PTSD symptoms. A GAF score of 42 was assigned. The May 2009 VA treatment records note the Veteran had good hygiene and was polite, cooperative and neatly dressed. His speech was copious, but not pressured. His mood was good, and he had no suicidal or homicidal ideation, or audio or visual hallucinations. His insight and judgment were good, and his cognition was generally intact. He had a GAF score of 55. The June 2009 VA day treatment records indicated that the Veteran wanted to decrease his anxiety and insomnia. There was no significant change in his mental status examination or in his risk of suicide or violence. He was given a GAF score of 40 and the highest GAF score during the past year was 42. Several other June 2009 treatment records noted complaints of nightmares, flashbacks, occasional numbness, being easily startled, irritable and impatient and easily angered. The Veteran also reported that these symptoms had decreased over the years and that his coping strategy was to "just relax." His symptoms occurred every few days and were attenuated by drug use. He endorsed some mild concentration problems and chronic insomnia. It was noted that the Veteran's substance abuse was partially driven by ongoing PTSD symptoms that he described as ongoing but not severe. He denied that his PTSD symptoms were currently disabling. Although the Veteran minimized his PTSD symptoms, he was placed on medication. He stopped taking his medication within a week of starting it. His GAF scores during this month were 50 and 60. A July 2009 VA treatment record indicates that no deficits were found on the mental status examination. A GAF score of 60 was assigned. In August 2009, the Veteran reported that he was experiencing many more PTSD symptoms since he started treatment for hepatitis C. He became quite tearful while describing recurring thoughts of the war and preparations he had to make then to survive. He used to cope by using heroin but was no longer using or having cravings and was determined not to use again. Objectively, he was depressed and tearful and denied suicidal or homicidal ideation. On the May 2010 VA examination, the Veteran continued to endorse PTSD symptoms that included flashbacks, nightmares, re-experiencing and increased physiological arousal when exposed to trauma-related cues, avoidance of trauma-related thoughts/places/activities, social isolation, sleep disturbance, irritability, hypervigilance and increased startle response. Since his last VA examination in 2005, he reported that his symptoms were variable with less frequent flashbacks and better control of his irritability that he attributed to maturity and infrequent socialization. He admitted to recent drug and alcohol use and he was not currently involved in any mental health treatment. The Veteran did not currently have any close or supportive relationships with any family members or have any friends or other significant social contacts; he was highly socially withdrawn. He described having no current leisure pursuits and he indicated that he had little pleasure in hobbies. He denied having any episodes of physical violence or suicide attempts since his last examination. On the mental status examination, he presented as sub-optimally groomed and casually dressed with signs of self-neglect that included noticeable facial stubble in addition to a mustache. He was initially to be evaluated in a room with no windows, which he reported made him too anxious. He therefore asked to be evaluated in a room with window or, in the alternative, have the door to the room left open. After he was moved to a room with a window, he was less anxious and was able to tolerate having the door closed. He was found to be alert but not fully oriented to time since he was aware of the date and year but indicated the current month June instead of May. With prompting, he was able to identify the correct month. The Veteran's affect was flat and his mood congruent. His speech was normal but the content was generally logical yet markedly tangential. Due to inconsistent accounts regarding his substance abuse history, he was considered to be a questionable historian. He reported a history of trauma and auditory hallucinations while experiencing flashbacks. He denied other symptoms of psychosis; therefore, his auditory hallucinations were most likely symptoms of re-experiencing his trauma. He denied suicidal or homicidal ideation and he was not considered a danger to self or others. His insight and judgment were impaired. His GAF score was 41. The VA examiner noted that the Veteran continued to meet the criteria for a PTSD diagnosis and that there was a well-established history of polysubstance dependence. He appeared to have current and ongoing struggles with PTSD and with maintaining sobriety. The PTSD symptoms appeared to be moderately severe. There was some indication of mild improvement in his PTSD as evidenced by his reported decrease in flashbacks and increased ability to effectively cope and manage his ager and irritability. Nevertheless, the examiner found that he continued to display significant psychosocial impairment. At the time of the examination, the psychologist only had electronic records, the May 2005 VA examination, and the clinical interview with the Veteran; the claims file had not been available. The examiner did, however, have an opportunity later to review the claims file and, in a May 2010 addendum, commented that the review of the claims file did not change the findings. Although the RO assigned staged ratings of 30 percent and 50 percent for the periods prior to and from May 7, 2010, as noted above, for the service-connected PTSD, the Board finds that the disability picture more closely resembles the criteria for a 70 percent rating throughout the entire appeal period. The service-connected PTSD has been, for the most part, frequently manifested by flashbacks, anxiety, nightmares, impaired sleep, anger, hypervigilance, avoidance of people, irritability, difficulty with authority figures, isolation, claustrophobia, and impulsivity. These symptoms have been shown to be productive of impairment more closely resembling deficiencies in work, family relations, judgment, and mood. Specific examples include the Veteran's difficulty in adapting to structured inpatient treatment, verbal disputes, discussions and concerns regarding his behavior and temper, difficulty with authority figures, and substance abuse partially driven by PTSD symptoms. The record also shows he did not have close relationships with family members, friends, or significant social contacts. Although the symptoms were fairly consistent over the years, his GAF scores have been as low as 30 and as high as 60 with the majority of the scores in the 45 to 50 range. The Board has considered the probative value of GAF scores, but due to the extreme range in GAF scores that appear in the record, sometimes even within the same month, the Board finds that the symptoms and manifestations themselves are more probative in determining the level of disability than the GAF scores. While there were brief fluctuations in the Veteran's symptoms over the years, the Board does not find that these variations have been significant enough to warrant the assignment of staged ratings; therefore, by resolving all reasonable doubt in the Veteran's favor, a 70 percent rating is warranted for the entire period. A higher rating of 100 percent is not warranted as the service-connected PTSD does not produce total occupational and social impairment. Notably, an April 2006 record notes he had a slightly disheveled appearance in April 2006, on May 2010 VA examination he had sub-optimal grooming he was not fully oriented to time by providing the wrong month, these symptoms do not demonstrate or approximate total occupational and social impairment in the absence of additional manifestations representative of total impairment. Further, when viewed on conjunction with the other evidence, his level of impairment is not considered total. Although the Veteran tends to isolate himself, mental status examinations have shown him to be cooperative, friendly, and reasonable. He is not considered a threat to self or others, there is no evidence of persistent delusions or hallucinations, and his memory is primarily intact. The Board has also considered whether referral for an extraschedular rating is indicated. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 115 (2008). However, there is nothing in the record that reflects or suggests that the service-connected PTSD is productive of an unusual or exceptional disability picture as to render impractical its rating under the provisions of the criteria applied in this case. The current 70 percent rating indicates a significant degree of impairment resulting from the service-connected PTSD, but there is no evidence that the disability is unusual or exceptional. The manifestations presented by this disability are contemplated and encompassed by the schedular criteria and are consistent with the current rating. Accordingly, on this record, those criteria are not inadequate and the criteria for submission for assignment of an extraschedular rating for this disability pursuant to 38 C.F.R. § 3.321(b)(1) are not satisfied. ORDER An increased rating of 70 percent for the service-connected PTSD is granted, subject to the regulations controlling disbursement of VA monetary benefits. ____________________________________________ JOHN H. NILON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs