Citation Nr: 1300650 Decision Date: 01/08/13 Archive Date: 01/16/13 DOCKET NO. 07-16 144 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to a disability rating in excess of 50 percent for the period prior to February 2, 2011, and in excess of 70 percent for the period beginning February 2, 2011, for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Haddock, Associate Counsel INTRODUCTION The Veteran had active military service from October 1966 to October 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. Jurisdiction over the case was subsequently returned to the VA RO in Montgomery, Alabama. The Board notes that, in addition to the paper claims files, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims files or are irrelevant to the issue on appeal. This case was previously before the Board in September 2010, at which time the issue currently before the Board was remanded for additional development. The case has now been returned to the Board for further appellate action. The Board notes that in the September 2010 remand, the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was added to the appeal as a part of the Veteran's claim for increase disability rating for PTSD in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). A review of the record shows that in a June 2010 rating decision, the Veteran was granted entitlement to a TDIU. There is no indication from the record that the Veteran has expressed his disagreement with the effective date assigned in that decision. Therefore, the Board has limited its consideration accordingly. A review of the record shows that the Veteran was afforded a VA psychiatric examination in June 2010 that was not considered by the Agency of Original Jurisdiction (AOJ) in conjunction with his claim of entitlement to an increased disability rating for PTSD. However, following the issuance of the January 2012 Supplemental Statement of the Case (SSOC), the Veteran submitted a statement in February 2012 in which he waived his right for AOJ consideration of new evidence that had not been previously considered by the AOJ. Therefore, a remand for the sole purpose of AOJ consideration of the June 2010 VA examination report is not necessary and the Board has proceeded with a final decision in this case. FINDINGS OF FACT 1. For the period prior to June 1, 2010, the occupational and social impairment from the Veteran's PTSD has more nearly approximated reduced reliability and productivity. 2. For the period beginning June 1, 2010, the occupational and social impairment from the Veteran's PTSD has more nearly approximated deficiencies in most areas, but not total occupational and social impairment. CONCLUSION OF LAW The criteria for a disability rating of 70 percent, but not higher, for the period beginning June 1, 2010, for PTSD have been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The record reflects that the Veteran was mailed a letter in September 2004 advising him of what the evidence must show and of the respective duties of VA and the claimant in obtaining evidence. In an April 2007 letter, the Veteran was provided the notice with respect to the disability-rating and effective-date elements of a claim. In a March 2009 letter, the Veteran was provided notice with respect to the disability rating criteria for PTSD and the effective-date element of his claim. Although the Veteran was not provided adequate notice until after the initial adjudication of the claim, the Board finds that there is no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development the claim was readjudicated. There is no indication or reason to believe that the ultimate decision on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). The Board also finds the Veteran has been afforded adequate assistance in response to his claim. The Veteran's service treatment records (STRs) are on file, VA Medical Center treatment notes have been obtained, and the Veteran has been afforded appropriate VA examinations. Neither the Veteran nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claim. The Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the claim. Legal Criteria Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). 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 their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). 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. PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. This diagnostic code uses the general rating formula for mental disorders, which provides a 50 percent rating for a mental disorder 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; and difficulty in establishing effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. The maximum schedular rating of 100 percent is warranted for a mental disorder 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. 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 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. In September 2004, the Veteran was afforded a VA examination. At that time, the Veteran reported that he experienced frequent intrusive thoughts and recollections about his combat experiences in the Republic of Vietnam. He reported that he had nightmares three to four times a week and that while he took medication to help his sleep, he still only got approximately three to four hours of sleep a night. He reported that he was hypervigilant and that this also caused him to experience sleep disturbances as he would awaken at night anytime he thought he heard the slightest sound. The Veteran reported that he experienced flashbacks regularly, indicating that the sounds of helicopters were especially problematic in this respect. He also reported an exaggerated startle response. The Veteran reported that he isolated himself from others and reported that he liked to stay by himself most of the time. He reported that he avoided crowds, television shows and movies related to the Republic of Vietnam, fireworks displays, and talking with others about his experiences in the Republic of Vietnam. The Veteran reported feelings of alienation and reported that people no longer looked at him the way they used to, which caused him to feel like he did not belong. The Veteran reported that he had difficulty trusting others and really only trusted his wife. He reported that he had a difficult time getting emotionally close to other people and that although he loved his wife and daughter, they did not have the easiest of relationships. The Veteran reported that he kept his back to the wall in order to feel comfortable in his surroundings. He reported that he experienced difficulty with concentration and that he would often forget what he was looking for. The Veteran reported that he frequently felt depressed and that he had lost interest in pleasurable activities. He reported that he experienced survivor's guilt, especially with respect to the fact that he had friends "go down" in the Republic of Vietnam right next to him and that he wondered why they died and he did not. The Veteran also reported that he experienced frequent feelings of rage. The Veteran denied any social relationships and reported that he did not engage in leisure pursuits. Upon mental status examination, the Veteran's thought processes and thought content were both noted to be within normal limits. Delusions and hallucinations were not present. The Veteran made good eye contact and his behavior was appropriate. The Veteran denied experiencing suicidal or homicidal thoughts, ideation, plan, or intent. The Veteran was able to maintain minimal personal hygiene and other basic activities of daily living. The Veteran was fully oriented and his long-term memory was intact. The Veteran's short-term memory and concentration were impaired. The Veteran's judgment was intact. The Veteran's speech was slow, his mood was depressed, and his impulse control was impaired. The examiner confirmed the diagnosis of PTSD and noted that the clinical interview indicated that the Veteran continued to struggle with major symptoms of PTSD and that the symptoms were now frequent, persistent, chronic, and moderate in nature with no real periods of remission. The examiner assigned a Global Assessment of Functioning scale (GAF) score of 51 and indicated that this was representative of moderate social and occupational impairment due to his PTSD. The examiner further noted that the Veteran experienced moderate difficulty obtaining gainful employment, whether physical or sedentary, due to his service connection PTSD. The examiner further noted that the Veteran had a poor prognosis for improvement. At this juncture, the Board notes that GAF scores are based on a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. The GAF score is based on all of the Veteran's psychiatric impairments. A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or a 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). A GAF score of 41-50 indicates 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). A GAF score of 51-60 is assigned for 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 coworkers). A GAF score of 61-70 represents 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. While particular GAF scores are not contained in the VA schedule of ratings for mental disorders, 38 C.F.R. § 4.130, they are a useful tool in assessing a Veteran's disability and assigning disability evaluations. However, they are just one of many factors considered when determining an evaluation. In January 2008, the Veteran was afforded another VA examination. At that time, the Veteran reported that he had been depressed which caused him to have unnecessary altercations with his wife. The Veteran denied having any social relationships and noted that other than his wife and children, he would speak with his sister occasionally. He reported that he used to play golf, but that he had completely lost interest in the activity. He reported that he was unable to do anything as a result of the medication he was taking and that he basically just laid around and watched television, "wasting time." The Veteran was noted to be taking an anti-anxiety medication and an anti-depressant. The Veteran reported that he had begun to drink a couple of shots of alcohol a few times per week despite his past history with alcohol abuse. The Veteran reported sleep disturbances, but also reported that he had begun to experience significant improvement in his sleep pattern. He reported that he still had difficulty sleeping two or three times per week and that he would be tired during the day and take naps. The Veteran vaguely reported experiencing auditory and visual hallucinations of people talking to him, but was unable to provide details. The Veteran reported that he had difficulty with memory and concentration in that he would often forget things that his wife told him to do. Upon mental status examination, the Veteran was found to be casually and appropriately dressed. The Veteran's psychomotor activity and unremarkable, but his speech was slow. The Veteran was cooperative toward the examiner, but his eye contact was poor. The Veteran's affect was flat and his mood was dysphoric. The Veteran's attention was intact and he was oriented to person, time, and place. The Veteran's thought processes and thought content were unremarkable. The Veteran did not have delusions. The Veteran was reported to understand the outcome of his behavior and knew that he had a problem. There was no objective evidence of auditory or visual hallucinations. The Veteran did not exhibit inappropriate behavior, he interpreted proverbs correctly, and he did not exhibit obsessive or ritualistic behavior. The Veteran did not have panic attacks and he denied suicidal and homicidal ideations. The Veteran's impulse control was noted to be fair and he did not have a history of violence. The Veteran was noted to be able to maintain personal hygiene and there was no problem with his activities of daily living. The Veteran's remote and immediate memories were normal and his recent memory was mildly impaired. The examiner confirmed the diagnosis of PTSD and noted that it was moderate in nature. The examiner assigned a GAF score of 55 and reported that while the Veteran might exhibit decreased efficiency and productivity and was mildly impaired in maintaining interpersonal relationships, he was not considered unemployable as a result of his PTSD. The examiner specifically noted that the Veteran exhibited symptoms of PTSD to include recurrent and intrusive recollections, nightmares, avoidance, markedly diminished interest or participation in significant activities, feelings of detachment and estrangement from others, sleep disturbances, irritability, angry outbursts, hypervigilance, and exaggerated startle response. The examiner noted that the Veteran's prognosis was fair with treatment. In June 2010, the Veteran was afforded another VA examination. At that time, the Veteran reported that he continued to live with his wife and daughter and described his marriage as fair. He attributed most of the problems with his marriage to himself. The Veteran stated that he and his daughter, who lived at home, "don't get along well," and that he was prone to get irritable with her. He reported that he maintained good relationships with his other two children. The Veteran reported that he had one friend that he saw approximately once a month, but reported that he did not socialize with group members. The Veteran reported that he used to play golf, but was unable to play it anymore and so, spent approximately 99 percent of his time sitting around the house. The Veteran reported that when he went out in public, he felt that people were looking at him and talking about him. The Veteran reported that things had been pretty rough lately and that he had been in a bad mood. The Veteran reported difficulty with sleep maintenance in that he would awaken some nights and have to walk outside. He reported that on some nights, he did not fall asleep at all and other nights he would get a couple of hours of sleep. He reported that he took naps during the day. The Veteran reported that he experienced ongoing difficulty with irritability and anger. The Veteran reported that sometimes he thought he heard babies crying and people hollering for their lives. The Veteran reported that his memory was getting pretty bad in that he lost things, forgot what his wife had told him to do, and reported that he had to write everything down. He reported that he took several different psychotropic medications and attended mental health counseling and medication management for treatment of his PTSD. Upon mental status examination, the Veteran was found to be neatly groomed and appropriately dressed. His psychomotor activity and speech were unremarkable, although he was noted to have little spontaneous speech. The Veteran's attitude was cooperative and attentive, but he made little eye contact. The Veteran's affect was blunted and his mood was dysphoric. The Veteran's attention was intact and he was oriented to person, time, and place. The Veteran's thought process and content were unremarkable. However, the examiner noted some paranoid ideation. The Veteran did not experience delusions and he was noted to understand the outcomes of behavior. The Veteran was also noted to understand that he had a problem. The examiner noted that the Veteran experienced auditory hallucinations, but that they were not persistent. The Veteran did not exhibit inappropriate behavior. The Veteran did not interpret proverbs correctly. He did not exhibit any obsessive or ritualistic behavior. The Veteran experienced persistent panic attacks. The Veteran denied homicidal ideations; however, the Veteran reported that he experienced suicidal ideations, but denied any attempts and denied any plan or intent. The Veteran's impulse control was noted to be fair and there was no indication that he experienced episodes of violence. The Veteran was noted to be able to maintain minimum personal hygiene. The Veteran's remote and immediate memories were noted to be normal, but his recent memory was noted to be mildly impaired. The examiner continued the diagnosis of chronic PTSD and assigned a GAF score of 50. The examiner noted that the Veteran's PTSD caused him to experience moderate to severe impairment in psychosocial functioning. The examiner noted that the Veteran's impairment was manifested by symptoms such as recurrent and intrusive recollections, avoidance, markedly diminished interest in participation in significant activities, feelings of detachment and estrangement from others, and sleep disturbances. The examiner noted that while the Veteran was currently unemployed, he was not solely unemployable as a result of his PTSD. Further, the examiner reported that the Veteran's prognosis for improvement was fair to guarded. In February 2011, the Veteran was afforded another VA examination. At that time, the Veteran reported that he continued to live with his wife and adult daughter. He reported that he argued with them a lot and that it was not because of anything they did, he would just snap at them. He reported that his daughter would often tell him that he was mean. He further reported, however, that he had OK relationships with his other two children who did not live at home. The Veteran reported that other than visiting with one friend once or twice per month, he did not socialize. He reported that he used to play golf, but that he no longer was able. He reported that he and his wife and daughter would sometimes go out for dinner, but that he felt like people stared at him which caused him to ask them what they were looking at. He reported that this caused his daughter embarrassment when they were out together. The Veteran reported that approximately 65 percent of the time he was fine, but that he would get into bad moods. The Veteran reported that he experienced difficulty sleeping, in that he would have nightmares approximately four times per week. He reported that he might get three hours of sleep per night and that he took naps during the day. The Veteran reported that he experienced panic attacks that were not associated with flashbacks. He could not identify the triggers for his panic attacks, but he reported that he tried to avoid crowds and fireworks. He reported that at times he heard babies crying and people hollering for their lives. The Veteran reported that he sometimes had memory problems. Upon mental status examination, the Veteran was found to be clean and appropriately dressed. The Veteran was noted to have turned his chair sideways, away from the examiner, so that he could see the door. His speech was unremarkable, but there was little spontaneous speech noted. The Veteran's attitude was cooperative and attentive, but he was noted to make almost no eye contact. The Veteran's affect was blunted and his mood was dysphoric. The Veteran's attention was intact and he was oriented to person, time, and place. Thought process was unremarkable, but the Veteran was noted to have some paranoid ideations. The Veteran did not experience delusions and was noted to understand the outcomes of behavior. The Veteran was noted to understand that he had a problem. The examiner reported that the Veteran experienced auditory hallucinations, but that they were not persistent. The Veteran did not exhibit inappropriate behavior. The Veteran did not interpret proverbs correctly. The examiner noted that the Veteran did not exhibit obsessional or ritualistic behavior. The Veteran experienced persistent panic attacks. The Veteran did not have homicidal ideations, but he reported that he continued to experience suicidal ideations without plan or intent. The Veteran's impulse control was fair and there was no evidence that he experienced episodes of violence. However, the Veteran did experience ongoing difficulty with anger and irritability. The Veteran was noted to be able to maintain minimum personal hygiene and it was noted that his PTSD did not present any problems with regard to his daily activities. The Veteran's remote and immediate memories were normal, but his recent memory was mildly impaired. The examiner confirmed the diagnosis of chronic PTSD and assigned a GAF score of 50. The examiner noted that the Veteran's PTSD caused him to experience moderate to severe impairment in psychosocial functioning. The examiner noted that the Veteran's impairment was manifested by symptoms such as recurrent and intrusive recollections, avoidance, markedly diminished interest in participation in significant activities, feelings of detachment and estrangement from others, and sleep disturbances. The examiner noted that the Veteran's prognosis for improvement was guarded. The examiner opined that the Veteran was at least as likely as not, for practical purposes, unemployable due to his PTSD alone. In this regard, the examiner noted that even with the Veteran's present circumstances of no employment or significant external demands, he continued to have moderately severe impairment in psychosocial functioning and that if the Veteran were to be employed, the increased stress due to work responsibilities would likely exacerbate his PTSD symptoms and render him completely unemployable. A review of the record shows that the Veteran receives mental health counseling and medication management at the VA Medical Center. A review of the VA Medical Center treatment notes of record shows that during his visits, the Veteran routinely complains of PTSD symptoms such as nightmares, depression, social isolation, loss of interest in activities, lack of motivation, and feelings of hopelessness. The Veteran has been described as having a flattened affect and a depressed mood. Additionally, the VA Medical Center treatment records show that the Veteran is maintained on various psychotropic medications for control of his symptoms, to include anti-depressant and anti-anxiety medications. However, the Board notes that the more recent VA Medical Center mental health treatment notes reflect decreased feelings of depression. The Board finds that the Veteran is not entitled to a disability rating in excess of 50 percent for the period prior to June 1, 2010. In this regard, the Board notes that for this period, the Veteran's PTSD has been manifested by symptoms of depression, sleep disturbance, nightmares, difficulty in maintaining interpersonal relationships, diminished interest, isolation, disrupted affect and mood, angry outbursts, hypervigilance, exaggerated startle response, and irritability. Additionally, during this period, the Veteran was assigned GAF scores of 51 and 55 by the September 2005 and January 2008 VA examiners respectively. These scores indicated that the Veteran experienced moderate impairment. Specifically, the Board notes that the January 2008 VA examiner specifically stated that the Veteran's PTSD symptoms were moderate. Therefore, the Board finds that the symptoms exhibited by the Veteran during this period more nearly approximate those contemplated by the 50 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. Consideration has been given to assigning a higher disability rating for this period. However, there is no indication from the evidence of record that the Veteran has experienced occupational and social impairment with deficiencies in most areas. In this regard, the Board notes that the Veteran did not show excessive difficulty in judgment and thinking, he did not have suicidal or homicidal ideations, he did not exhibit obsessional rituals which interfered with routine activities, he did not have delusions, there was no objective evidence of hallucinations, and he did not experience panic attacks. There was no indication from the record that the Veteran was unable to maintain his personal hygiene. Therefore, the Board finds that a disability rating of 70 percent was not warranted for the period prior to June 1, 2010. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board finds that the Veteran is entitled to a disability rating of 70 percent for the period beginning June 1, 2010. In this regard, the Board notes that this was the date of the Veteran's VA examination which first showed the Veteran to have occupational and social impairment with deficiencies in most areas. This was manifested by such symptoms as depression, anxiety, suicidal ideations, auditory hallucinations, paranoid ideations, inability to interpret proverbs correctly, persistent panic attacks, sleep disturbances, and increased social isolation. Additionally, the VA examiner specifically noted that the Veteran's PTSD had worsened, in that it was now moderate to severe in nature. Further, the VA examiner assigned a GAF score of 50, which is indicative of serious impairment. The Veteran was also noted to have ongoing difficulty in controlling his anger outbursts and irritability. Therefore, the Board finds that the symptoms exhibited by the Veteran for the period beginning June 1, 2010, more closely approximate those contemplated by the 70 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board acknowledges that the results of the VA examinations and the symptoms described in the VA examination reports, the Veterans Center mental health clinical summaries, and the various private and VA Medical Center mental health treatment notes do not indicate that the Veteran experiences all of the symptoms associated with a 70 percent disability rating for a psychiatric disability. However, the Court has held that the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, a finding that there is occupational and social impairment resulting in deficiencies in most areas is sufficient to warrant a 70 percent disability rating for the period beginning June 1, 2010, even though all the specific symptoms listed for a 70 percent rating are not manifested. Consideration has been given to assigning a higher disability rating for the period beginning June 1, 2010. However, the Board finds that there is no reasonable basis for concluding that the social and occupational impairment during this period more nearly approximated total rather than deficiencies in most areas. In this regard, there is no indication from the evidence of record that the Veteran had 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, the veteran's intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and significant memory loss (i.e. for names of close relatives, own occupation or own name). While the February 2011 VA examiner did note that the Veteran should be considered unemployable as a result of his PTSD alone, the Board notes that the Veteran did not also exhibit symptoms of total social impairment. In this regard, the Veteran was able to maintain a marriage with his wife of many years in addition to good relationships with two of his adult children. Additionally, the Veteran was reported to have one or two friends that he visited with at least once a month. The Veteran also attends group therapy at the VA Medical Center and actively engages in such. Further, the Board notes that the finding of unemployability was based on the examiner's belief that the increased stress of working would cause the Veteran's symptoms to get worse. The examiner did not find that the Veteran's current symptoms of PTSD rendered him unemployable. Therefore a higher evaluation is not warranted for the period beginning June 1, 2010, or at any time prior thereto. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The Court has held that the threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the manifestations of the disability are contemplated by the schedular criteria. There is also no indication from the evidence of record that the Veteran has had frequent hospitalizations or has even received frequent emergency treatment for his PTSD. Additionally, while the Veteran has not worked during the pendency of this appeal, it is well established in the record that his inability to work was a result of his physical disabilities and not solely a result of his PTSD. Additionally, the Board notes that the Veteran was awarded entitlement to TDIU effective August 2009. Further, as noted above, the February 2011 VA examiner's finding of unemployability solely due to his PTSD was based on the belief that the increased stress of working would cause the Veteran's symptoms to get worse. The examiner did not find that the Veteran's current symptoms of PTSD rendered him unemployable. In sum, there is no indication that the average industrial impairment from the disability would be to such a degree as to warrant the assignment of a higher disability rating than that granted herein for any period on appeal. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. Thun, id. ORDER The Board having determined that the Veteran's PTSD warrants a 70 percent disability rating, but not higher, for the period between June 1, 2010, and February 1, 2011, the benefit sought on appeal is granted to that extent only and is subject to the criteria applicable to the payment of monetary benefits. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs