Citation Nr: 1222294 Decision Date: 06/26/12 Archive Date: 07/02/12 DOCKET NO. 08-08 849 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an initial disability rating higher than 30 percent for posttraumatic stress disorder (PTSD) from August 31, 2005 to October 31, 2011, and to a rating higher than 50 percent since November 1, 2011. . REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Ann L. Kreske, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1968 to March 1970. This appeal to the Board of Veterans' Appeals (Board) is from a February 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. That decision, in relevant part, granted the Veteran's claim for service connection for PTSD and assigned an initial 30 percent rating retroactively effective from August 31, 2005, the date of receipt of his claim. He appealed for a higher initial rating. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a Veteran appeals his initial rating, VA must consider whether to "stage" the rating to compensate him for times since the effective date of his award when his disability may have been more severe than at others). In October 2011, the Board remanded the claim to the RO, via the Appeals Management Center (AMC), for further development and consideration. This additional development especially included obtaining any outstanding evaluation or treatment records and having the Veteran reexamined to reassess the severity of his PTSD. Upon completion of this additional development and consideration of the additional evidence obtained on remand, including the results of the VA examination, the AMC issued a decision in January 2012 increasing the rating for the PTSD from 30 to 50 percent as of November 1, 2011, the date of that VA examination. He since has continued to appeal for an even higher rating. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (indicating that receiving a higher rating, but less than the highest possible rating, does not abrogate an appeal unless the Veteran expressly indicates he is satisfied with the new rating he received). So his appeal now concerns whether he was entitled to an initial rating higher than 30 percent for his PTSD from August 31, 2005, to October 31, 2011, and whether he has been entitled to a rating higher than 50 percent for this disability since November 1, 2011. FINDINGS OF FACT 1. From August 31, 2005, to October 31, 2011, the Veteran's PTSD caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. But there is no competent and credible indication it also caused reduced reliability and productivity during those years. 2. Since November 1, 2011, his PTSD has caused this additional reduced reliability and productivity, but there is no competent and credible indication it has caused deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. From August 31, 2005, to October 31, 2011, the criteria are not met for a rating higher than 30 percent for the PTSD. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. §§ 4.1-4.14, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2011). 2. Since November 1, 2011, the criteria also are not met for a rating higher than 50 percent for the PTSD. Id. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Duties to Notify and Assist VA has duties to notify and assist the Veteran in substantiating this claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Proper notice from VA must inform him of any information and medical or lay evidence not of record: (1) that is necessary to substantiate this claim; (2) that VA will obtain and assist him in obtaining; and (3) that he is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These Veterans Claims Assistance Act (VCAA) notice requirements apply to all elements of his claim, including the "downstream" disability rating and effective date elements. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 438 F.3d 1311 (2007). Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then going back and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC) - such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). See, too, Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (wherein the U.S. Supreme Court made clear that VCAA notices errors in timing or content are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of showing there is a VCAA notice error and, moreover, above and beyond this, that it is unduly prejudicial, meaning outcome determinative of his claim). In this case, a letter satisfying the notice requirements of 38 C.F.R. § 3.159(b)(1) was sent to the Veteran in November 2005, prior to initially adjudicating his claim, so in the preferred sequence. The letter informed him of the evidence required to substantiate his claim and of his and VA's respective responsibilities in obtaining this supporting evidence - keeping in mind that his claim at the time was for service connection for his PTSD, which since has been granted in the February 2006 decision from which this appeal ensued. In Dingess, and subsequently in Goodwin v. Peake, 22 Vet. App. 128, 137 (2008), the U.S. Court of Appeals for Veterans Claims (Court/CAVC) held that, in cases, as here, where service connection has been granted and an initial disability rating and effective date assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. Thereafter, once a notice of disagreement (NOD) has been filed contesting the "downstream" issue of the initial rating assigned for the disability, the notice requirements of 38 U.S.C. §§ 5104 and 7105 regarding a rating decision and SOC control as to the further communications with the appellant, including as to what evidence is necessary to establish a more favorable decision with respect to this downstream element of the claim. Id.; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) and VAOPGCPREC 8-2003 (Dec. 22, 2003). And, here, the Veteran received this required SOC in January 2008, also SSOCs in March 2009 and January 2012 discussing this downstream claim for a higher initial rating, citing the applicable statutes and regulations, and providing reasons and bases for initially rating the PTSD as 30-percent disabling, but no greater, and then as 50-percent disabling, but no greater. VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of his claim that is obtainable, and, therefore, appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). The RO and AMC obtained his service treatment records (STRs), VA treatment records, and arranged for VA compensation examinations to assess and then reassess the severity of his PTSD. Indeed, the Board's October 2011 remand of this claim was to obtain additional evaluation or treatment records, which the AMC did, and to have him reexamined, which also as mention occurred on November 1, 2011, and served as the basis for increasing the rating for his PTSD from 30 to 50 percent as of that date. The medical and other evidence in the file, including the results of this most recent VA examination, provide the information needed to properly rate this disability, both prior to and since November 1, 2011, so additional examination is not needed to decide this appeal. 38 C.F.R. §§ 3.327(a), 4.2. See also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Allday v. Brown, 7 Vet. App. 517, 526 (1995); VAOPGCPREC 11-95 (April 7, 1995); and Green v. Derwinski, 1 Vet. App. 121 (1991). Moreover, in obtaining the additional evaluation and treatment records and having him reexamined, there was compliance with these October 2011 remand directives. See, e.g., Stegall v. West, 11 Vet. App. 268 (1998) (indicating a Veteran is entitled to compliance with remand directives, as a matter of law, and that the Board itself commits error in failing to ensure compliance). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Thus, as there is no indication that any other relevant evidence remains outstanding, the duty to assist has been met. 38 U.S.C.A. § 5103A. II. Whether Higher Ratings are Warranted for the PTSD Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. See 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the Veteran's favor. 38 C.F.R. § 4.3. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Since the Veteran's claim arises from his disagreement with the initial rating assigned following the granting of service connection, some discussion of the Fenderson case is warranted. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). In this case, the Court noted the distinction between a new claim for an increased evaluation of a service-connected disability and a case, as here, in which the Veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been service-connected. In the former situation, the Court held in Francisco v. Brown, 7 Vet. App. 55, 58 (1994), that the current level of disability is of primary importance. In the Fenderson scenario, however, where, as here, the Veteran has expressed dissatisfaction with the assignment of an initial rating, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim - a practice known as "stated" rating. Fenderson, 12 Vet. App. 125-26. The Court also since has extended this practice even to cases that do not involve initial ratings, rather, established ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether they were expressly raised, as well as the entire history of the Veteran's disability in reaching its decision. See 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). The Veteran's PTSD was rated as 30-percent disabling from August 31, 2005, to October 31, 2011, and has been rated as 50-percent disabling since November 1, 2011, under 38 C.F.R. § 4.130, Diagnostic Code 9411. He contends that both ratings should be higher to reflect the severity of his symptoms. Mental disorders are evaluated under the general rating formula for mental disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. When evaluating a mental disorder, the evaluation must be 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. 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). As provided by the Rating Schedule, a 30 percent disability rating is appropriate when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 39 C.F.R. § 4.130, Diagnostic Code 9411. A higher rating of 50 percent under the general rating formula for mental disorders is appropriate when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. An even higher 70 percent rating is warranted when there is 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); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as", followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In evaluating the evidence, the Board also has noted various Global Assessment of Functioning (GAF) scores contained in the DSM-IV, which clinicians have assigned. A GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. The higher the GAF score, the higher the overall functioning of the individual is. For instance, a score of 41-50 illustrates "[s]erious 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)." DSM-IV at 46-47. A score of 51-60 represents "[m]oderate 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)." Id. A. From August 31, 2005, to October 31, 2011 The evidence of record during this initial time period at issue includes December 2005 and April 2006 VA treatment records showing the Veteran had complaints of anxiety since his return from Vietnam, depression, poor appetite, low energy level, insomnia, irritability, and poor concentration. He also reported re-experiencing combat-related trauma in the form of recurrent, distressing memories and dreams. He exhibited avoidance behavior, avoided public places, felt "on edge" when in public, and was socially withdrawn. However, he denied suicidal or homicidal ideations, hallucinatory experiences, and symptoms suggestive of hypomanic/manic episodes. No delusional thinking was expressed or elicited. Mental status examination revealed that he was calm and cooperative, had good eye contact, had normal psychomotor activity, showed spontaneous and soft speech, had "alright" mood, and had appropriate and constricted affect. He had no suicidal or homicidal ideations, or hallucinations or delusions. His thought process was coherent, logical, and goal-directed. He was alert and oriented. And his insight was good and judgment was intact. His GAF score was 55. He was provided a VA compensation examination in January 2006 in connection with his initial claim for service connection for PTSD. During that examination, he reported being treated from 1990 to 1991 for "seeing things on the floor." He was treated with medication for a short period of time, and his symptoms resolved. At the time of that examination, he was taking an anti-depressant and a sleep aid. He reported having worked at the scrap yard for 14 years, indicating that he enjoyed his job, but did not like the people with whom he worked because they "kept cutting [him] out of things, especially money." He also reported having lost several jobs over the years due to use of alcohol. But he denied current use of alcohol or of drugs. As for symptoms of PTSD, he reported "feeling like everybody [was] looking at him" and being afraid of being pulled over by the police for no reason. He also experienced difficulty being around people, was anxious in crowds, and liked to work alone, though he could work with others. He reported daily thoughts about Vietnam. As well, he did not sleep well and dreamed of Vietnam. And he reported becoming upset more often, and becoming easily irritated. He additionally indicated having trust issues with others, and having no friends. Also reported was a long history of ill will against the Vietnamese people. Watching news associated with the Iraqi war increased his symptoms. There also was reported hypervigilance and mild exaggerated startle response, especially to loud noise. But he denied hallucinations. Objective examination showed that he was alert and oriented in all spheres, had fair eye contact, had regular rate and rhythm in his speech, had coherent thought process, had no suicidal or homicidal ideations, and had adequate insight and judgment. There was no overt psychosis. The diagnosis was PTSD. The GAF score was 70. The examiner indicated that the Veteran had mild functional impairment. No other treatment records dated in 2006 show complaints of, or treatment for, PTSD. VA treatment records dated in 2007 generally noted subjective complaints of feeling jumpy, severe nightmares, social isolation, re-experiencing of combat-related trauma in the form of recurrent dreams and memories, avoidance behavior, hypervigilance, anxiety, depression, insomnia, poor appetite, low energy level, irritability, and lack of concentration. But the Veteran also reported nightmares that decreased in intensity and in frequency after Celexa was prescribed. Nevertheless, he also reported catching a "glimpse of shadows out of the corner of [the] eye" and realizing that they were not real. He additionally reported taking a flight to visit relatives and feeling "closed in around so many people" during the flight. And he indicated having trouble leaving home at night, but denied suicidal or homicidal ideations. Mental status examinations showed that his mood was dysthymic, his affect was anxious, his thought process and content were organized, and his insight and judgment were fair. He was alert, well-oriented, with good concentration and attention, and no evidence of gross difficulty. It was noted that he initially showed anxiety, but became more relaxed as he and his treating physician became better acquainted, but he remained tense. He had no psychosis and no suicidal or homicidal ideations. It was noted that he had minimal improvement, mostly in the frequency/intensity of nightmares. His GAF score in 2007 was 49. VA treatment records dated in 2008 noted subjective complaints of ongoing severe symptoms of PTSD that were affecting the Veteran at work, feelings of irritability and depression, feelings of stress due to financial difficulties, loss of interest in things, anxiety, self-isolation, and an inability to tolerate crowds. He reported being reprimanded three times at work for arguing with co-workers, and felt that his job would have been in jeopardy had he not been employed there for a long time. He also reported having difficulty remembering to take his medication two times a day. He indicated he was having severe nightmares, waking up in a sweat and hitting and kicking his wife in his sleep. Nevertheless, he denied suicidal or homicidal ideations. Mental status examination revealed speech that was quick and anxious in tone; a tense posture; an irritated and anxious mood; organized thought process and content, with no psychosis, suicidal or homicidal ideations; continued severe nightmares; and good insight and judgment. He was alert, well-oriented, had good concentration and attention, and had no evidence of gross difficulty. It was noted that he continued to have significant PTSD symptoms that interfered with his function at home and at work. But he still managed to continue working, though it was proving to be difficult. His GAF score in 2008 was also 49. In February 2009, the Veteran reported not doing well. The number of hours he worked had been cut to the point where he felt he could no longer afford to pay his bills, and he feared losing his house. He reported feeling very irritable and feeling like "what's the use" at times. But he continued to deny thoughts of suicide or homicide. He also reported still having nightmares. He was anxious and irritable, his speech was quick and anxious in tone, his mood was anxious, and he had a tense posture, but his thought content and process were organized, there was no evidence of psychosis, there was no evidence of suicidal or homicidal ideations, and his insight and judgment were good. As well, he was alert and oriented, and had good concentration and attention. When seen in December 2009, his speech was normal, his affect appropriate, his thought process linear and goal-directed, and his motor activity within normal limits. He also denied perceptual disturbances such as hallucinations. He was alert, attentive, and oriented. His judgment was intact and he had insight. VA treatment records dated in 2010 documented reports of nightmares and intrusive thoughts, insomnia, worries about housing due to financial stresses, avoidance behaviors, anxiety, anger, and depression, but denials of suicidal or homicidal ideations, psychosis, and mood swings. In September 2010, he reported losing his job, but it was noted in another VA treatment record that it was due to the place of business (a steel mill) closing - so not because of his PTSD. Mental status examinations revealed that he was alert, cooperative, oriented, and had no or mild cognitive impairment. His speech was of normal rate and tone, his motor activity was within normal limits, his mood was moderately depressed, and his affect was anxious and depressed, but his thought process was logical and goal-directed, his abstract thinking was normal, and he had no perceptual disturbances. His judgment was normal and his insight was present. His GAF score was 45. Mental status examinations in 2011 revealed good eye contact; normal psychomotor activity; spontaneous and normal speech; euthymic, anxious, or depressed mood; appropriate affect; no suicidal or homicidal ideations; no hallucinations or delusions; thought process that was coherent, logical, and goal-directed; and fair judgment and insight. The Veteran was alert and oriented. A March 2011 VA summary of evaluation and treatment of PTSD indicated the Veteran participated in Cognitive Processing Therapy that had proved to be unhelpful as his symptoms were chronic and severe and affected his daily functioning, to include social and occupational. These symptoms included intrusive thoughts of combat trauma, nightmares, severe anxiety, exaggerated startle response, social withdrawal, depression, chronic insomnia, isolation, irritability, poor concentration, occasional flashbacks, and feeling powerless and hopeless over his life. May 2011 VA psychiatric treatment notes reflect reports of increased situational stress due to the Veteran's children living at his home, but he continued to deny psychosis, mood swings, depression, suicidal and homicidal ideations. April 2011 and May 2011 mental status examinations found he had normal speech and blunted affect, but thought process ranging from good or fair to linear and goal-directed. He also denied hallucinations and delusions. He was alert, attentive, and oriented. His mood was moderate, with affect congruent to his mood. No suicidal risks were assessed. Mental status examinations from June to October 2011 also generally revealed good eye contact, normal psychomotor activity, spontaneous and normal speech, moderate or depressed mood, affect congruent with mood, and good insight and judgment. There also were no suicidal or homicidal ideations and delusions. And he was found to be coherent, logical, and goal-directed, as well as alert and oriented. There were no suicidal risks. Based on the foregoing, the evidence of record does not support assigning a rating higher than 30 percent during this initial period. 38 C.F.R. § 4.7. For the most part, the Veteran exhibited the type, frequency and severity of symptoms required for the existing 30 percent rating, but not those required for a higher 50 percent or even greater rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding that the factors listed in the rating formula are mere examples of conditions that warrant a particular rating and are used to help differentiate between the different evaluation levels). Specifically, during this initial period, the medical evidence of record showed no objective findings of flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding difficult commands; impairment of long-term memory; impaired judgment; or impaired abstract thinking. And while he reported having trouble remembering to take his medication, an indication of impaired short-term memory, and seeing "shadows" out of the corner of his eye, both of these complaints were reported only once and were not shown to be consistent or persistent. Moreover, although he also experienced social withdrawal and difficulty with relationships with his colleagues, including at work, he nevertheless was able to maintain employment and, by all indications, was not for as examples demoted or rated less than satisfactory in the performance of his job. There equally is no indication that the reduction ("cut") in the number of hours he worked each day and week was the result of his PTSD versus other unrelated factors, especially since the steel mill at which he worked eventually closed. So while there admittedly was some impairment in these respects, it is sufficiently contemplated by the criteria commensurate with a 30 percent rating - as, for example, in comparison to the higher 50 percent rating. His GAF scores during this initial period were generally in the 41-50 range (specifically, once 45 and twice 49), indicative of "[s]erious 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)." On two other occasions, however, during 2005 and 2006, it instead was considerably higher - 55 and even 70. And the mental status examinations he had generally did not reveal objective findings of symptoms as might be expected for those lower, versus higher, GAF scores, such as suicidal ideation or severe obsessional rituals. DSM-IV at 46-47. In fact, to the contrary, he generally denied having suicidal or homicidal ideations during this period. He also was able to maintain employment, albeit with difficulty at times. And in any event, as explained, although an examiner's classification of the level of psychiatric impairment at the moment of examination by a GAF score is to be considered, it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. Here, the evidence on the whole during this initial time period at issue indicated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but not also with reduced reliability and productivity. So a 30 percent rating, as opposed to a higher 50 percent or even greater rating, is the most appropriate for this initial period. B. Since November 1, 2011 For this immediately succeeding period to the present, the Board also finds that the Veteran's PTSD symptoms have not been so severe as to warrant an even higher rating of 70 or 100 percent. The Board's review of the evidence in the file reveals that, while he has experienced worsening PTSD symptoms during this more recent period at issue, these symptoms are not so severe as to cause occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. The most pertinent medical findings assessing the severity of his PTSD during this ensuing period are from his VA compensation examination on November 1, 2011. The November 2011 VA examiner diagnosed chronic PTSD as well as adjustment disorder with depressed mood that was due to then recent stressors in the Veteran's life, such as almost losing his home, and not the result of his PTSD. See 38 C.F.R. § 3.310(a) and (b) (permitting service connection on this secondary basis for disability that is proximately due to, the result of, or chronically aggravated by a service-connected disability); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). During that additional examination, the Veteran reported having a good relationship with his wife and son, but not his daughter. He denied having social friendships and relationships. He attended church one to two times a month and enjoyed fishing and watching football games on television, though he was unable to attend the games in person due to his avoidance of crowds. He denied suicidal attempts and physical altercations since the 2006 initial examination, but had been involved in shouting matches. He had last worked in 2010, when he was fired after working for the same employer for almost 17 years. As for the criteria required for PTSD, he had recurrent and distressing recollections of the traumatic event that he had experienced during service, including thoughts, images, perceptions, or dreams; intense psychological distress at, and physiological reactivity on, exposure to internal or external cues that symbolized or resembled an aspect of the traumatic event; avoidance of thoughts, feelings, or conversations associated with the trauma; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; difficulty staying or falling asleep; irritability or outbursts of anger; difficulty concentrating; and hypervigilance. He had a depressed mood, panic attacks that occurred weekly or less often, chronic sleep impairment, impaired abstract thinking, and occasional suicidal ideation. He was angry, irritable, and resentful. His affect was constricted, and he was depressed. The examiner also noted the Veteran had perseverative speech, was reportedly fired at work for being unable to function on a new machine, had impaired abstract thinking, no relationships outside of his family, had occasional suicidal ideation without intent or plan, depressed mood, and chronic sleep impairment. During testing, he remembered 1/3 of the words after an interval and a second with a clue. The examiner indicated that, although the Veteran had more than one mental disorder diagnosed - namely, PTSD and adjustment disorder - it was possible to attribute some of the symptoms to the PTSD and not to the adjustment disorder. Specifically, the examiner indicated that the symptoms of re-experiencing, cue avoidance, hypervigilance, social withdrawal, and occasional panic attacks were attributable to the PTSD, while the symptoms of increased intensity of depression and suicidal ideation were attributable to the adjustment disorder. Some symptoms, however, were common to both disorders and could not be differentiated, including irritability and anger, sleep disturbance, anhedonia, and impaired concentration and memory. In Mittleider v. West, 11 Vet. App. 181, 182 (1998), the Court explained that VA adjudicators must be able to distinguish, by competent medical evidence, the extent of symptoms that is due to service-related causes, i.e., service-connected disability, from that which is not, and that, when it is not possible or feasible to make this distinction, VA adjudicators must resolve this doubt in the Veteran's favor according to 38 C.F.R. §§ 3.102 and 4.3, and effectively presume all symptoms in question are attributable to the service-connected disability. So when, as here, a VA examiner affirmatively has indicated that some symptoms, such as irritability and anger, sleep disturbance, anhedonia, and impaired concentration and memory, cannot be differentiated and are common to both PTSD and adjustment disorder, they must be associated with the PTSD and must be considered as part and parcel of the PTSD, and resultantly factored into the overall rating for this condition. This is especially significant here because the November 2011 VA examiner found that the Veteran's suicidal ideations - one of the criteria required for a 70 percent rating - were due to his nonservice-connected disorder and not due to his service-connected PTSD. This examiner also assigned a GAF score of 51, indicative of just relatively "[m]oderate 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)." DSM-IV at 46-47. Nevertheless, he confirmed the Veteran had occupational and social impairment with reduced reliability and productivity, so was entitled to the higher 50 percent rating rather than the 30 percent rating that initially had been assigned. VA treatment records dated since the November 1, 2011, VA examination to April 2012, subsequently associated with the claims file, also contain no evidence that a higher 70-percent rating is warranted for the Veteran's service-connected PTSD. Generally, VA treatment notes dated from November 2011 to April 2012 documented normal speech; dysphoric, depressed, or stable mood; and congruent, constricted, or blunted affect, but his thought process was linear and goal-directed. He also had normal psychomotor activity, and denied perceptual disturbances. And he was alert, attentive, and oriented. Judgment ranged from fair to good, and insight also was fair to good. No suicidal or homicidal ideations or delusions were noted. The Veteran was alert and oriented. And while April 2012 VA treatment records noted complaints of increased anxiety regarding family relationships, feeling overwhelmed with caring for his grandchildren, and feeling low energy and motivation, they also noted mental status examinations with similar findings as those earlier in the year. So as of November 1, 2011, the date of that VA compensation examination, the Veteran's PTSD began to be rated at this higher level. He has not however shown the type and degree of functional and occupational impairment that is required for even higher 70 or 100 percent ratings, such as by having evidence of deficiencies in most areas or total occupational and social impairment. So a 50 percent rating, as opposed to a higher, 70 or 100 percent rating, is the most appropriate under 38 C.F.R. § 4.130, Diagnostic Code 9411, for the period since November 1, 2011. C. Extra-Schedular Consideration In exceptional cases, where schedular evaluations are found to be inadequate, the RO or Board may refer a claim to the Under Secretary for Benefits or to the Director of Compensation and Pension Service for consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1). The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id. The Board is precluded from assigning an extra-schedular rating in the first instance, having instead as mentioned to refer the matter to the Under Secretary for Benefits or the Director of Compensation and Pension Service for this initial consideration when suggested by the record or specifically claimed. See Barringer v. Peake, 22 Vet. App. 242 (2008). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1). Here, though, the Board finds no evidence this disability has markedly interfered with the Veteran's employment, meaning above and beyond that contemplated by his initial 30 percent and now higher 50 percent schedular ratings. See 38 C.F.R. § 4.1, indicating that, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See, too, Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (reiterating that the disability rating, itself, is recognition that industrial capabilities are impaired). While he reported during his November 2011 VA compensation examination that he had been "fired" from his job due to his inability to work or maintain a new machine, there was no indication this was because of his PTSD. Also, he indicated that he had worked for the same employer for almost 17 years and, yet, just the prior year, so in 2010, he had indicated that his job at the steel mill was terminated, not because of his PTSD, rather, because the steel mill closed down. Furthermore, there is no evidence of any other exceptional or unusual circumstances, such as frequent hospitalizations, suggesting he is not adequately compensated for this disability by the regular Rating Schedule. His evaluation and treatment for his PTSD has been primarily, if not exclusively, on an outpatient basis, not as an inpatient, much less frequent inpatient. See Bagwell v. Brown, 9 Vet. App. 237, 238-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). ORDER From August 31, 2005, to October 31, 2011, the claim for an initial disability rating higher than 30 percent for the PTSD is denied. Since November 1, 2011, the claim for a rating higher than 50 percent for the PTSD also is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs