Citation Nr: 1237496 Decision Date: 11/01/12 Archive Date: 11/09/12 DOCKET NO. 09-17 385 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to an initial evaluation higher than 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002 & Supp. 2012). The Veteran served on active duty from March 26, 1958 to November 14, 1958. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, granting service connection and a 10 percent evaluation for PTSD, effective July 12, 2006. The Veteran appealed from the initial assigned disability rating. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a veteran appeals the initial rating for a disability, VA must consider the propriety of a "staged" rating based on changes in the degree of severity of it since the effective date of service connection). By an April 2009 rating decision, the RO increased from 10 to 50 percent the evaluation for PTSD, effective August 24, 2005. The claim for a still higher disability rating remains on appeal, however, absent an express withdrawal by the Veteran. See A.B. v. Brown, 6 Vet. App. 35, 39 (1993) (the claimant is presumed to be seeking the highest possible rating for a disability unless he or she expressly indicates otherwise). In August 2010, a Travel Board hearing was held before the undersigned. Relevant to this proceeding, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the individual who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the basis of the prior determination was noted and the elements of the claim that were lacking to substantiate the claim for benefits were discussed. In addition, any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim was discussed. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2). The hearing focused on the elements necessary to substantiate the claim. The Board can adjudicate the claim based on the current record. Following the hearing, in September 2011 the Board remanded this case for further evidentiary development. The matter has since returned for an appellate disposition. FINDINGS OF FACT 1. Since the Veteran submitted the 2005 claim for service connection underlying this appeal, his PTSD has been primarily manifested by symptoms including irritability, depression, and difficulty sleeping, and assigned Global Assessment of Functioning scores have ranged from 50 to 60, but the Veteran has recently remarried and maintains relationships with his children and grandchildren, and maintains hobbies and interests, despite his PTSD. 2. The Veteran's service-connected PTSD has not involved occupational and social impairment, with deficiencies in most areas, during the pendency of this claim. CONCLUSION OF LAW The criteria are not met for an initial evaluation higher than 50 percent for PTSD. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist the Claimant The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2002 & Supp. 2012), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. Implementing regulations are codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must inform the claimant of any information and evidence (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will seek to provide on the claimant's behalf. A regulatory amendment effective for claims pending as of or filed after May 30, 2008 removed the requirement that VA specifically request the claimant to provide any evidence in his or her possession that pertains to the claim. 73 Fed. Reg. 23,353-56 (Apr. 30, 2008), later codified at 38 CFR 3.159(b)(1) (2012). In regard to the claim on appeal for higher initial evaluation for service-connected disability, the requirement of VCAA notice does not apply. Where a claim for service connection has been substantiated and an initial rating and effective date assigned, the filing of a Notice of Disagreement with the RO's decision as to the assigned disability rating does not trigger additional 38 U.S.C.A. § 5103(a) notice. The claimant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to either of these "downstream elements." See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). See also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). This is the case here, in that the claim for service connection for PTSD has been substantiated, and no further notice addressing the downstream disability rating requirement is necessary. The RO (including through the Appeals Management Center (AMC)) has taken appropriate action to comply with the duty to assist the Veteran through obtaining records of VA outpatient treatment, and arranging for him to undergo VA Compensation and Pension examinations. See 38 C.F.R. §4.1 (for purpose of application of the rating schedule accurate and fully descriptive medical examinations are required with emphasis on the limitation of activity imposed by the disabling condition). In furtherance of his claim, the Veteran has provided a private treatment counselor's statement, and several personal statements from himself. He testified during a Board hearing. There is no indication of any relevant evidence or information that has not already been obtained. The record as it stands includes sufficient competent evidence to decide the claim. Under these circumstances, no further action is necessary to assist the Veteran. In sum, the record reflects that the facts pertinent to the claim have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. That is to say, "the record has been fully developed," and it is "difficult to discern what additional guidance VA could [provide] to the appellant regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F. 3d. 1369 (Fed. Cir. 2004). Accordingly, the Board will adjudicate the claim on the merits. Background and Analysis Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Where the veteran appeals the rating initially assigned for the disability, after already having established service connection for it, VA must consider the propriety of a staged rating that is indicative of changes in the severity of the course of his disability over time. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court recognized a distinction between a veteran's dissatisfaction with an initial rating assigned following a grant of service connection and a claim for an increased rating of a service-connected disorder. In the case of the assignment of an initial rating for a disability following an initial award of service connection for that disability (the circumstances of the present appeal), separate ratings can be assigned for separate periods of time based on the facts found - "staged" ratings. See Fenderson, supra, at 125-26. The VA rating schedule provides that psychiatric disorders other than eating disorders, including PTSD, are to be evaluated according to a General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under that formula, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating may be assigned where 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; obsessed rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The symptoms and manifestations listed under the above rating formula are not requirements for a particular evaluation, but are examples providing guidance as to the type and degree of severity of these symptoms. Consideration also must be given to factors outside the rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). From review of the evidence in this case, the June 2006 correspondence from a private mental health counselor states that the Veteran had been under psychological treatment since February of that year. It was the opinion of this therapist that the Veteran's depression was aggravated by his military experience. A VA Compensation and Pension examination by a psychiatrist was completed in September 2008. The Veteran then described problems with social dysfunction, difficulty maintaining relationships, and difficulty functioning socially as well as maintaining employment and mood stability. He described having had therapy and counseling over the past few years, and was not on any medication at that time. The Veteran reported mood instability and social avoidance. He lived alone after divorce from his wife of over 30 years. He had some sleep disturbance, chronic back pain, periodic problems with depression and mood, and difficulty getting along with people. On a mental status examination the Veteran was alert and oriented times three. Mood appeared to be somewhat anxious, but he tended to intellectualize at times. He was not suicidal, not homicidal. There were no hallucinations or delusions. He described having had "multiple personalities" as a way of a coping mechanism. He also dissociated at times as a way of coping with his difficult childhood, especially his history of sexual abuse of which he had some flashbacks and intrusive thoughts of still. His eye contact was fair to good. He complained of decreased hearing, but there was no mania and no pressured speech. He was somewhat verbose. Activities of daily living appeared to be normal. Memory on a short-term basis appeared fine. The diagnosis given was PTSD secondary to childhood traumas; and personality disorder with mixed features. The Global Assessment of Functioning (GAF) score that was provided was 50, considering impairment of functioning for PTSD, with an overall score GAF score of 40, when impairment due to PTSD on Axis I was considered in combination with all other disorders, to include Axis II psychiatric disorder and impairment due to the Veteran's physical disorders, including coronary artery disease, status post cardiac surgery and cardiac stenting and congestive heart failure. The VA examiner further commented that while the Veteran was diagnosed with emotional instability and narcissism in the military, he noted he had a history of sexual abuse which he still had intrusive thoughts and flashbacks about. He had a history of trauma for his mother who used to physically abuse him. He grew up with an alcoholic father. He had sleep disturbance, anxiety, problems with depression, and mood instability. His childhood stressors could obviously be rated as severe. Therefore, it was deemed at least as likely as not that the Veteran met the DSM-IV criteria for PTSD based on his childhood traumas. There was also evidence though that the Veteran had a great amount of difficulty getting along with people. He had mood instability with personality dysfunction. He actually had a history of some antisocial acts such as having an affair with his brother's wife and producing a child, and going to prison in the 1960s for burglary. He had multiple affairs in his previous marriage. He also complained of dissociation. Therefore, it was deemed at least as likely as not that he met the DSM-IV criteria for personality disorder with mixed features. He had had social dysfunction due to a number of causes including his personality dysfunction and his history of numerous affairs. The examiner who conducted the 2008 VA examination opined that the Veteran's current employment dysfunction was due to his physical problems. The Veteran reported self-employment for many years as a carpenter and roofer because he was unable to work in a capacity which required him to interact with others. The Veteran reported that he was unable to continue with that type of work after cardiac problems were diagnosed that required surgery in 2000. The examiner opined that the Veteran's capacity for improvement and remission of his psychiatric condition was helped by the fact that he did not abuse substances, he had sought out treatment in the past, and he had a relationship with a significant other at the time of the 2008 VA examination. During his August 2010 hearing testimony, the Veteran described symptoms that included mood swings, including periods of anger. He stated that he was undergoing treatment for early stages of Alzheimer's disease and Parkinson's disease. He described having "pseudo-seizures" that were brought on by stress. He stated that thoughts of suicide had entered his mind on occasions. He indicated having rituals where if one thing disturbed those rituals, his whole day was thrown off. According to the Veteran, he had "split personalities" through which he could change personalities at any time to deal with life circumstances. He indicated sleeping on average three to four nights per week. Also described was some short and long term memory loss. Records of VA outpatient treatment include an April 2011 psychiatric consult, which indicated that the Veteran took various psychotropic medications which seemed to work well, and he reported no disabling anxiety or depression at that time. The Veteran reported good response to the existing medicines, and the psychiatrist saw no reason to adjust them. It was noted that there was something of a lighthearted playful demeanor to the Veteran as he tossed out all kinds of previous diagnoses. He talked about pseudoseizures, schizophrenia and multiple personality disorder. It seemed that, in view of his long struggle, if he was stable the medicine should simply be continued. On further VA examination of October 2011, by a psychologist, the assigned diagnoses were PTSD, chronic; personality disorder, not otherwise specified (NOS); and adjustment disorder, NOS. As to relevant psychosocial history, since the last VA examination the Veteran had recently married his significant other. The Veteran related that he got along well with his wife, and she had learned to handle his occasionally "spiteful" behavior. The Veteran reported that he had maintained good relationships with his children and grandchildren. He reported that, despite his physical limitations, he tried to stay active. Meanwhile, he stated he had been unable to work since approximately 2000 due to his multiple medical conditions. He described continuing to receive mental health treatment, including through psychotropic medication. It was noted that the Veteran had made some positive changes in the way he handled his anger, but remained prone to outbursts and some attention-seeking behavior. He denied any legal or behavioral problems since the last examination. He denied drug use and reported only occasional alcohol use of 1-2 drinks since he quit drinking heavily more than 20 years ago. With regard to his recent functioning, the Veteran stated he would still get depressed, but he now knew more about what was happening. The greatest depression point was a lack of appreciation. He described a continuing "split personality" disorder which he stated he had learned to control, although he remained unable to handle people in authority positions. He also noted issues with anger control, and lashing out verbally at times towards his family, though overall he described his relationships in positive terms. The Veteran reported that he felt he was having increasing difficulty with his memory, stating that he had been diagnosed with Alzheimer's disease. On mental status examination, the Veteran was casually dressed and adequately groomed. He was alert and fully oriented, displaying no gross memory impairments or difficulties with concentration. He was cooperative with the assessment process though his interactions were charming but fairly superficial. His mood was euthymic and affect full range. He displayed good eye contact and was somewhat tremulous. Speech was normal in rate and tone, spontaneous and goal-directed, but overproductive and he had a mild stutter at times. His though processes were organized with no evidence of formal thought disorder, hallucinations, delusions, or obsessive-compulsive features. He appeared to be of average intelligence, capable of abstract thinking, and displayed fair insight into his PTSD and related emotions and behaviors, appearing to have internalized much in his years of psychotherapy. The Veteran displayed no difficulties with activities of daily living, and denied suicidal or homicidal ideation or panic attacks. Due to records indicating the Veteran had been diagnosed with dementia, a mini-mental status exam was administered to gauge his cognitive functioning, and he scored a 29 out of 30 on this measure indicating no presence of cognitive impairment. Consultation with the Veteran's treating psychologist also failed to reveal any indications of significant cognitive deficits, though the Veteran's subjective complaints of declining memory were noted. It was further observed that the Veteran was competent for VA purposes and able to manage VA funds. He demonstrated no measurable impairment of cognitive functioning and had been successfully managing his financial affairs with the assistance of his wife. The VA examiner summarized that the Veteran had PTSD secondary to childhood abuse, aggravated by military service. Results of the examination revealed the Veteran to be functioning emotionally at levels similar to those indicated in his 2008 review exam. Since that time, the Veteran had married his longtime partner, who was his primary caregiver, and had begun receiving in-home medical and counseling services through the VA home-based primary care program. He had continued to experience mood and sleep difficulties, which appeared to fluctuate largely upon his medical issues and pain management, with the Veteran becoming more irritable, depressed and isolative when his physical health deteriorated. He continued to display a preoccupation with his early traumas, reporting frequent nightmares of indistinct content, from which he awakened in an agitated, "pseudoseizure" state. Evidence of disordered personality functioning also remained apparent, with the Veteran displaying a psychological way of relating to the world around him, which likely stemmed from his early abuse experiences and anti-social acting out, aggravated by his emotional deterioration while in the military. This resulted in his chronic difficulties interacting with others, particularly those in positions of authority, and in coping with daily stressors. When environmental stressors increased or the Veteran's normal coping mechanisms were depleted due to chronic pain or other medical conditions, his emotional stability and psychosocial functioning declined further. While the Veteran's occupational function during his working years (prior to the submission of this claim in 2005) had been negatively impacted by his PTSD and personality issues, his current primary impairment in this area was due to his declining physical health, the examiner opined. Thus, his baseline functioning due to his PTSD and personality disorder, conditions that were largely indistinguishable as personality dysfunction stemmed from child abuse, was assessed to be consistent with a GAF score of 60. Functional impairment due to his adjustment disorder secondary to medical issues was consistent with a GAF of 50. Prognosis for substantial improvement of psychiatric symptoms or functional status was poor, given the chronicity of his impairment, but was likely to remain stable at existing levels, barring significant decline in physical functioning. Based upon the evidence of record, the Board has determined that the current assigned 50 percent disability rating remains the most accurate approximation of the degree of disability associated with the Veteran's service-connected PTSD. In so finding, the Board has given comprehensive consideration to the relevant evidence, particularly insofar as whether any of the substantive denoted criteria under Diagnostic Code 9411 are met, and whether there is any comparable symptomatology that corresponds to a higher 70 percent level. When viewed overall, the evidence from 2005 to the present best indicates that the Veteran manifests occupational and social impairment with reduced reliability and productivity, consistent with assignment of a 50 percent rating, but no worse than this level based on objective symptomatology shown. The Board acknowledges that the Veteran's occupational or social impairment may have fluctuated during his adult life, but the Board emphasizes that the current assignment of an initial rating must be based on the functioning shown during the pendency of this claim, that is, since the Veteran submitted the 2005 initial claim for service connection. To begin with, the Veteran has described symptoms of difficulty interacting with others, mood disturbances, and some sleep disturbances. This having been elucidated, the Board does not find further additional symptoms that are generally associated with a more serious level of mental health impairment, as the examiners have stated that there is no evidence of a thought disorder, or any impairment of verbal communication. The report of the October 2011 VA Compensation and Pension examination in particular provides a telling portrayal of service-connected disability as having involved continuing symptomatology, but with current symptoms a substantially less debilitating type of condition than the Veteran's current impairments due to declining physical health. Mood at this time was euthymic, and mental health treatment including psychotropic medication was working as planned (a fact confirmed though the above-mentioned April 2011 VA outpatient progress note). The Veteran had also experienced some positive changes in dealing with anger. The Veteran also was noted to have good relationships with family members. He had recently remarried, and this was described as a supportive and beneficial association. The Board readily acknowledges the Veteran had continuing mental health symptoms and treatment, and the Veteran has described this as well on examination and in hearing testimony. However, the evidence in its entirety also portrays improvement in symptomatology over the course of the pendency of the appeal. However, the assigned initial rating is based on the most severe symptoms shown by the Veteran, not simply the current symptomatology as improved with medication control. Moreover, all the clinical evidence from 2005 to the present establishes that the Veteran retired prior to the 2005 claim for service connection for PTSD, due to nonservice-connected physical conditions, and there is no indication of inability to work during the pendency of this appeal, from 2005 to the present, occasioned by service-connected mental health disability. The October 2011 VA examiner clarified that the Veteran's mental health impairment was obviously detrimental to occupational capacity, but was not the driving factor behind the Veteran's retirement given supervening nonservice-connected factors. The Board has likewise considered that there is a general absence of signs and symptoms corresponding to the next higher 70 percent evaluation under Diagnostic Code 9411. The Veteran has indicated that he has considered or had thoughts about suicide in the past, but there is no clinical evidence or opinion that the Veteran has manifested suicidal ideation during the period at issue. The Veteran testified that he had "rituals" he followed, but there is no clinical opinion that these rituals interfere with his routine activities, although the Veteran testified that he would forget important things, such as eating, if his wife did not remind him. August 2012 Hearing Transcript (Tr.) at 4. The examiners and providers did not indicate that the Veteran's speech was intermittently illogical, obscure, or irrelevant, and his hearing testimony appeared logical and he responded to questions asked. The Veteran testified that he had numerous medical disorders. His providers and examiners noted that physical disorders required that the Veteran have assistance, but there is no opinion that panic or depression due to PTSD results in current impairment of the Veteran's ability to function independently, appropriately and effectively beyond the extent contemplated in the 50 percent initial evaluation assigned. The Veteran did not testify that he had spatial disorientation or that he neglected personal appearance or hygiene, although, again, the Board acknowledges that the Veteran testified that he was subject to forgetfulness and inability to cope with stress. The Veteran's symptoms of spatial disorientation, if any, and his difficulty in adapting to stressful circumstances (including work or a work-like setting) are consistent with the GAF scores ranging from 50 to 60 assigned by VA examiners and providers. While the Veteran has impairment of ability to establish and maintain effective relationships, the evidence establishes that he formed relationships with individuals of the opposite sex throughout the pendency of the appeal, and that he remarried and has remained remarried as of the time of the most recent VA examination. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Thus, the Board finds, as a matter of fact, that the Veteran's ability to form and maintain relationships is not impaired beyond the severity contemplated in the assigned 50 percent initial rating. The Board notes that there is medical evidence and opinion that the Veteran has a contemporaneous diagnosis of personality disorder NOS. Generally, VA law precludes an award of service-connected disability compensation upon the premise of a personality disorder. See 38 C.F.R. § 3.303(c). The Veteran has not specifically sought service connection for a personality disorder, nor has a claim for service connection for a personality disorder been adjudicated, nor does the Board interpret the Veteran's claim for service connection to include a disorder for which service connection is not authorized by law. The Board readily acknowledges that it is difficult to distinguish the symptoms of PTSD from personality disorder NOS in this case, as the VA examiner who conducted the most recent examination opined. Under such circumstances, therefore, all objective symptomatology shown must be presumed due to service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (where it is not possible to separate the effects of a service-connected disability from any nonservice-connected conditions by competent opinion, all symptoms must be attributed to the service-connected disability). See also, Howell v. Nicholson, 19 Vet. App. 535, 540 (2006). That notwithstanding, for reasons already indicated, there is no basis upon which the symptomatology shown corresponds to a higher evaluation under Diagnostic Code 9411. Taking into consideration the GAF scores assigned pursuant to VA examination these also do not necessarily correspond to the assignment of any increased evaluation for service-connected PTSD. The initial VA examination of September 2008 assigned a GAF score of 50. The subsequent examination of April 2011 indicated a GAF of 60 with regard to PTSD, and of GAF 50 due to adjustment disorder from unrelated medical issues; thus, some differentiation was possible between service-connected and nonservice-connected mental health impairment, and consequently the overall assigned GAF score for PTSD must be deemed to be that of 60. Generally, under the DSM-IVR, a GAF score in the 51 to 60 range is indicative of 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). A GAF score in the 41 to 50 range is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). As to the assigned GAF of 60 on the October 2011 VA examination, this score clearly corresponds to a moderate level of impairment, and is not suggestive of the more serious type of symptomatology contemplated by a 70 percent evaluation. Meanwhile, the GAF of 50 assigned pursuant to the September 2008 examination is also consistent with a level of impairment encompassed within the criteria for a 50 percent evaluation, since the VA examination report described serious and numerous disorders other than PTSD affecting the Veteran's functioning. When considered in light of the Veteran's actual objective symptomatology shown on the VA examination, the assigned GAF score correlates with a moderate rather than a severe degree of impairment due to PTSD. As noted above, the report of initial VA examination reflected both the Veteran's functioning throughout his life as well as his current functioning since he submitted the claim for VA benefits underlying the claim on appeal. The evidence as to current symptoms since the claim for VA benefits must be utilized as the proper rating basis rather than symptoms reported for functioning during prior periods. See 38 C.F.R. § 4.126(a) (when evaluating a mental disorder, the rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment. In summary, the assigned GAF scores do not substantiate any result different from the assignment of the existing 50 percent evaluation. Accordingly, the assignment of a 50 percent initial evaluation is warranted throughout the period at issue under the provisions of the VA rating schedule. Although some improvement in symptoms of PTSD is shown during the later part of the appeal period, doubt is resolved in the Veteran's favor to result in a finding of moderate impairment due to PTSD during the entire appeal period. The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1), which provides procedures for assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In Thun v. Peake, 22 Vet. App. 211 (2008), the Court articulated a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors, 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 extraschedular rating. In this case, there initially is no basis to find that the Veteran's psychiatric disorder presents such an exceptional disability picture that the applicable schedular criteria are inadequate. The applicable rating criteria found at Diagnostic Code 9411 contain a series of enumerated symptoms for ratings in excess of the assigned 50 percent rating, including a 100 percent rating. However, the Board has also evaluated the Veteran's psychiatric condition more generally and overall in terms of whether there are signs of total occupational and social impairment not directly listed in the rating criteria. There is no readily obvious more comprehensive way to evaluate psychiatric symptomatology, nor for that matter has the Veteran identified impairment clearly outside what the rating schedule would consider. Thus, the Board cannot conclude that the Veteran's current PTSD symptomatology is consistent with an exceptional disability picture as to render the schedular rating criteria inadequate. The first stage of the standard for determining availability of an extraschedular rating not having been met, the potential application of the next two steps becomes a moot issue. Regardless, the Board will give these stages due consideration. In this regard, however, the Veteran has not shown that his service-connected disability under evaluation has caused him marked interference with employment, meaning above and beyond that contemplated by his current schedular ratings. While the Veteran's psychiatric disorder limits his employability, the most recent VA examiner found limited impact of PTSD upon occupational functioning, and cited nonservice-connected physical medical conditions as the reason for the Veteran's retirement several years ago. The Veteran retains substantial capacity for social functioning and this conceivably would contribute to occupational capacity as well. Moreover, the Veteran's service-connected PTSD also has not recently necessitated frequent periods of hospitalization, or otherwise rendered impracticable the application of the regular schedular standards. In the absence of the evidence of such factors, the Board is not required to remand this case to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For these reasons, the Board is denying the claim for increased rating for PTSD. This determination takes into full account the potential availability of any "staged rating" based upon incremental increases in severity of service-connected disability during the pendency of the claim under review. The preponderance of the evidence is against the claim, and under these circumstances the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER An initial evaluation higher than 50 percent for PTSD is denied. ____________________________________________ TRESA M. SCHLECHT Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs