Citation Nr: 1301441 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 08-03 305 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran served with the Army National Guard from 1999 to 2008 with a period of active duty from December 2003 to March 2005. This case comes before the Board of Veterans' Appeals (the Board) on appeal from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio (RO), which, in pertinent part, granted service connection for PTSD and assigned an initial 30 percent rating. While the appeal was pending the RO in a November 2009 supplemental statement of the case granted a 50 percent rating for the PTSD from initial entitlement. The Veteran did not express satisfaction with this rating and it was forwarded to the Board, which remanded this issue for further development in October 2011. Such development has been completed and this matter is returned to the Board for further consideration. FINDING OF FACT The Veteran's service-connected PTSD is manifested by difficulty in establishing and maintaining effective work and social relationships, disturbances of motivation and mood, and impairment of short-term memory. CONCLUSION OF LAW The criteria are not met for an evaluation in excess of 50 percent for service-connected PTSD. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a , Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) (codified at 38 U.S.C.A. §§ 5100 , 5102-5103A, 5106, 5107, 5126), imposes obligations on VA in terms of its duty to notify and assist claimants. Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Specifically, VA must inform the claimant of any information and evidence not of record that (1) is necessary to substantiate the claim as to all five elements of the service connection claim (including degree of disability and effective date of disability); (2) VA will seek to provide; and (3) the claimant is expected to provide. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Dingess v. Nicholson, 19 Vet. App. 473 (2006); Quartuccio at 187. Notice should be provided at the time that VA receives a completed or substantially complete application for VA-administered benefits. See Pelegrini v. Principi, 18 Vet. App. 112 at 119 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). This timing requirement applies equally to the initial disability rating and effective date elements of a service connection claim. See Dingess. The Board finds that the VCAA letters sent to the Veteran in January 2006 and May 2006 essentially complied with the statutory notice requirements outlined above. VA notified the Veteran of the evidence obtained, the evidence VA was responsible for obtaining, and the evidence necessary to establish entitlement to the benefits sought including the types of evidence that would assist in this matter. Notice of the disability rating and effective date elements was provided in the May 2006 letter, prior to the April 2007 rating decision granting service connection. Here, the veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been 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. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. The claim was thereafter readjudicated in a supplemental statement of the case. VA has also satisfied its duty to assist the Veteran. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Veteran's service treatment records and VA treatment records have been associated with the claims folder. Additionally, VA has provided the Veteran with VA psychiatric examinations, most recently in November 2011. These VA examinations are adequate because they indicate that the examiners considered the Veteran's medical history, reviewed the Veteran's documented medical history, provided clinical findings, diagnoses, and opinions supported by medical rationale. Given the foregoing, there is no basis to find that these reports are inadequate, or that a remand for another opinion is required. See 38 C.F.R. § 3.159(d) (2012); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Board notes that the adequacy of these examinations have not been challenged by either the Veteran or his representative. Additionally, VA afforded the Veteran an opportunity to appear for a hearing, which the Veteran declined. The Board finds that there is no indication that there is any additional relevant evidence to be obtained either by the VA or by the Veteran, and there is no other specific evidence to advise him to obtain. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). Lastly, the Board notes that no action is necessary to comply with VA's duties to notify and assist are not applicable to matters in which the law, and not the evidence, is dispositive. See Mason v. Principi, 16 Vet. App. 129 (2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Accordingly, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Schedular Analysis The Veteran contends that his service-connected PTSD is more severely disabling than the current 50 percent evaluation. VA determines disability evaluations by applying a schedule of ratings, which represents for each disability an average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate rating codes identify the various disabilities. See 38 C.F.R. Part 4 (2012). When 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 (2012). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Additionally, factual findings may show distinct time periods when the service-connected disability exhibited symptoms that would warrant different ratings for different periods of time; in such a case, so-called "staged" ratings are appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). In the instant case, the Veteran's PTSD is rated under Diagnostic Code 9411 of the pertinent regulation. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). This diagnostic code is the most appropriate because it pertains specifically to the primary service-connected disability: PTSD. In any event, with the exception of eating disorders, all mental disorders, including PTSD, are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Moreover, the Veteran has not requested that another diagnostic code be used. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9411. The relevant criteria for evaluating PTSD are as follows: A 50 percent rating is appropriate 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 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 establishing effective work and social relationships. A 70 percent rating is appropriate for: 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 that 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 an inability to establish and maintain effective relationships. A 100 percent rating is appropriate for: 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 and place; memory loss for names of close relatives, own occupation or name. See 38 C.F.R. § 4.130 , Diagnostic Code 9411 (2012). When evaluating a mental disorder, the rating agency must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency must assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment, but it cannot assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). The Board notes that the specified factors for each incremental rating are examples rather than requirements for a particular rating, and the Board will not limit its analysis solely to whether the Veteran exhibited the symptoms listed in the rating scheme. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Also relevant to the Board's analysis is the Global Assessment of Functioning (GAF) assigned to the Veteran, which is a scale that reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown , 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). While the veteran's GAF score is not itself determinative of the most appropriate disability rating, the Board must consider it when evaluating the appropriate disability rating for the veteran. See VAOPGCPREC 10-95. Descriptions of the relevant GAF ranges are as follows: A GAF score ranging from 31 to 40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score ranging from 41 to 50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score ranging from 51 to 60 reflects 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). DSM-IV, pp. 46-47. See 38 C.F.R. § 4.130 (2012) (incorporating by reference the provisions of the DSM-IV for rating purposes.) In addition to the Veteran's service-connected PTSD, the Veteran's treatment history includes some findings suggestive of traumatic brain injury. The Board is precluded from differentiating between symptomatology attributed to a non- service connected disability and a service connected disability in the absence of medical evidence that does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The medical evidence in the instant case does not differentiate between the symptomatology associated with the Veteran's PTSD and that resulting from any TBI. Further, mental health professionals indicate that it is not possible in this instance to distinguish between said symptomatology. Accordingly, for the purpose of this decision, the Board will attribute all of the Veteran's psychiatric symptoms to his service connected PTSD. The Board now turns to an evaluation of the relevant medical evidence in the Veteran's case. Among private treatment records from 2005 was a May 2005 note that indicated he was diagnosed with PTSD with a prescription for Xanax given. A November 2005 private clinical assessment related a history of the Veteran having the following symptoms since he returned from Iraq in February 2005: problems sleeping, intrusive thoughts, hypervigilance, nightmares and startle response. He was uncomfortable around crowds and felt like he was being watched. He avoided war related stimuli and had emotional numbing. At night he was alert to noises and patrolled his home. He reported a great deal of repressed anger regarding the war, which resulted in explosive outbursts of anger towards his family, causing marital problems. Consequently he had depression and had his guns removed due to periodic suicidal ideations. Mental status examination revealed that he was a very verbal and willing informant. He was oriented but reported that when intrusive thoughts entered, he obsessively ruminated about them. He also exhibited short term memory deficit, particularly under stress. He had no alcohol or drug issues. He did endorse homicidal ideations when angry. He also had suicidal ideations when depressed. His depression was getting worse. He had no intent of either harm to self or others. His affect was appropriate to his mood. His insight was good and judgment was fair. He was diagnosed with PTSD and major depressive disorder. His GAF score was 50. Regular counseling was recommended. VA records from 2006 revealed that in a February 2006 psychiatric consult, adjustment disorder was diagnosed, with mental status findings indicating he was alert with appropriate affect with a mood that was less depressed, but with some sleep disturbance. He had no suicidal ideations at present. A depression screen of the same month was positive. An April 2006 social work note revealed him to be oriented, calm, focused, congenial and was dressed appropriately with excellent grooming and hygiene. He shared that he was seeing an outside therapist and was experiencing less frequent nightmares and flashbacks. He indicated that an antidepressant he was being prescribed was helping. He lived with his spouse and 2 children and currently worked in maintenance at a correctional facility. A May 2006 social work initial contact revealed the Veteran to describe issues including poor sleep of about 3 1/2 hours a night, fluctuating appetite, general indecisiveness but with a tendency at times to make brash decisions, less organized thinking than before, with a tendency to become sidetracked. He also reported having issues with lacking motivation and no longer caring about things he used to be meticulous about. He endorsed being less comfortable in crowds and needed to face doors in restaurants. He described being more easily agitated with anger problems. He also had flashbacks and nightmares and found himself having difficulty in adjusting to people who did not respond precisely to his directives-this included his own children and coworkers. He further endorsed hypervigilance, low energy levels, racing thoughts and poor short term memory. The assessment was PTSD and adjustment disorder with mixed anxiety and depressed moods. A cognitive psychotherapy note of the same month revealed him to be casually groomed, with blunt affect, spontaneous speech with a less depressed and irritable mood. A June 2006 VA social work assessment described the Veteran as suffering from nightmares and flashbacks several times a week. He lived with his wife and children and was close to his immediate and extended family. He also had several friends he was close with and belonged to fraternal and service organizations. He endorsed no history or current thoughts of self harm or harm to others. He enjoyed spending leisure time riding his 4 wheeler or playing with his dog. Vocationally he had worked in various jobs including building maintenance from 1997 to 2000, and since then worked as a correction officer for 5 years. He joined the National Guard in 1999. His strengths were listed as being a good provider, good citizen and being good with children and handy around the house. His weaknesses were described as a tendency to be impatient at times, being intolerant of imperfection and having high expectations mostly towards his children. He had intolerance for people he considered stupid. Overall he had anger problems including road rage. He was noted to meet the clinical criteria for a PTSD diagnosis. He reported poor short term memory but good long term memory. He was fully oriented to person, place, time and situation. He described having a variety of moods fluctuating from agitated, angry, anxious, appropriate, depressed, distrustful, fearful, irritable, lonely and intolerant of stupidity. He also had incongruent feelings, emotions and motivations from day today. His speech was appropriate, with no perceptual disturbances noted. His thought content was wide ranging, from antisocial attitude, guilt, helplessness, paranoid thinking, persecutory delusions, poverty of content, and guardedness/suspiciousness. His thought process was disorganized, yet logical and tangential. He was much more logical and goal directed in his thinking, but had been experiencing some disorganized thoughts and easily became side tracked. He was less able to multi task as he used to be. His judgment was fair and insight was good. The lone Axis I diagnosis was PTSD, with no Axis II diagnosis. His GAF score was 60. VA social work and psychiatry notes from August 2006 centered around the Veteran's reaction to incidents in which a fellow Guardsman apparently played some practical jokes on him while he was in summer training for the National Guard. The Veteran reacted very angrily to this individual and was seen by 2 different counselors after admitting that he had strong homicidal feelings towards the individual at that time, which subsided after he calmed down. He indicated that had his gun been loaded, the individual likely would have been killed. His reaction to this individual was described as being in the "battlemind state." He also discussed issues where his discipline of his young son for misbehaving was initially thought to be too harsh, but he was shown to have talked with his son about the punishment and his approach seemed relevant and appropriate as he was showing awareness of his potential and toning it down to a more appropriate level. He also reported enjoying participating in his children's activities and pride about his daughter's showing livestock at a county fair. A September 2009 social work note indicated that the Veteran ran out of medication for his nightmares, which resulted in them starting back up. He described putting in for an honorable discharge from the National Guard due to feeling alienated by his peers during drill downs. He reported returning to his spiritual roots and taking his family to church for the past 4 weeks. This along with the nightmare medications seemed to improve things. In August 2006 the Veteran's private counselor who had drafted the November 2005 report also wrote a letter to the National Guard that essentially recommended he be medically discharged from the National Guard due to his PTSD symptoms. The same history as given in the November 2005 report was repeated. Additionally, the Veteran was noted to describe anger as the most salient feature of his PTSD. He tried to walk from situations to calm down, but when unable to avoid a situation he exploded and he admitted having brief homicidal thoughts. However he had been able to control these impulses. He was noted to have depression triggered by anniversary dates of events in Iraq, with suicidal ideations at those times. He also had intrusive thoughts and flashbacks when driving. He indicated that drill weekends at the National Guard upset him greatly with constant discussions of Iraq. A November 2006 VA treatment record showed the Veteran to report doing better with his anger since going on his current medications. He thought they slowed down his anger process which gave him more time to think before doing things. He was still working at the correctional facility and hoped he could remain there as long as he could, but realized his psychiatric condition could potentially change things over time from a vocational standpoint. The report of a March 2007 VA examination for PTSD addressed the history and etiology of PTSD for the purpose of establishing service connection. At the time of this examination he remained in the National Guard but was in the process of procuring a medical discharge. His history regarding PTSD stressors was detailed. Occupationally his post Iraq history of having worked as a correctional officer but having to change to working in building maintenance due to his PTSD symptoms rendering him unable to work in his previous position. Socially he was married 12 years with a good relationship, with 2 children. He visited his parents several times a week. He had several friends and associates in his home town. He spent his free time coaching sports. He had no drug or alcohol problems or legal history. Mental status examination revealed him to be a reliable historian, with appropriate dress and appearance. His facial expressions were appropriate to verbal cues, and his eye contact was appropriate. His speech was normal and he had no involuntary movements. Cognitively he was alert and oriented to person, place, time and situation. His thought content was relevant. His recent and remote memory was grossly intact. He did have moderate degrees of paranoia in his thought process. He felt as though others were often watching him and he changed his behaviors due to this. He reported having "heightened" hearing since Iraq. He had no apparent deficits in attention and concentration. He displayed normal range and intensity of affects. He laughed and smiled at times during the interview. He described his general mood as "plain" not up or down. He endorsed problems falling asleep, with worries about household issues. His thought processes were future oriented and optimistic. There were no suicidal ideations, thoughts, plans or intent. He was assessed as meeting the criteria for PTSD, with this being the lone Axis I diagnosis. No Axis II diagnosis was given. His GAF score was 55. He was deemed capable of maintaining gainful employment and meaningful relationships despite his current symptoms. The symptoms interfered with his ability to function in his occupation as a juvenile officer and resulting in taking a lower paying position at this correctional facility. The quality of his relationship with his wife and children was also adversely affected. He was competent for VA purposes. The rest of the opinion dealt with the etiology of his PTSD which was found to be service connected. A January 2008 letter from the Veteran's private counselor since November 2005 described the Veteran as continuing with symptoms such as sleep disturbance, nightmares, intrusive thoughts, flashbacks, startle response and hypervigilance. He was described as attempting to cope by staying extremely busy with work and after work activities involved in school activities with his children. However this strategy to keep from thinking about his Iraq experiences and reducing symptoms was deemed unsuccessful. The counselor described the Veteran as presenting as an outgoing, verbal individual with a good sense of humor, but this was a façade. He continued to struggle with PTSD and when unable to repress his emotions, would explode with anger. Initially the anger was towards his family, but he realized his marriage and family relationship was suffering. Consequently he began taking his anger out on inanimate objects, and destroyed a washer he was unable to fix. This has been a more frequent response to stress. Work was also an added stressor, and his change in positions from correctional officer to building maintenance with a subsequent pay cut was noted. He also dealt with stress with frequent absenteeism from work. The counselor in the January 2008 letter opined that the Veteran suffers from serious PTSD and as a consequence of these symptoms and their impact on his life. He also was described as having a major depressive disorder. His relationship to his family, friends and coworkers was impaired resulting in difficulty establishing and maintaining effective relationships. His judgment was poor, as shown by his using anger to resolve stressful situations. Thus he also exhibited irritability, impaired impulse control and explosive outbursts. He had difficulty adapting to stressful situations both at work and in social situations. His behaviors had a negative impact on his marriage and relationship with his children. Denial of the severity of his symptoms was present, thus he presented as better than he actually was and used his sense of humor to deflect addressing his true feelings. In his January 2009 VA Form I-9, the Veteran reported his work relations as "horrible" at best and that family relations were worse. He indicated that he maintained full time employment by maxing out his sick and vacation leave. He also submitted documentation of his leave requests from work. A lay statement from the Veteran's wife in April 2008 described the Veteran as having changed greatly since he was in Iraq. Prior to Iraq, he was described as a very patient husband and father, who participated in various activities such as coaching and teaching Bible school, as well as working to improve the home. Since his return from Iraq, he was described as having horrible anger to the point where he damages objects, including appliances which then needed to be replaced. She also described him as previously having perfect attendance at work, but now took time from work at times when he believed people would kill him if he got out of bed. She also described that paranoid thoughts about others out to kill him resulted in his refusal to take the trash to the curb, and he refused to close his eyes when taking a shower due to his paranoid thoughts. She also described him as reporting hypersensitive hearing to noises nobody could possibly hear, such as the dog drinking water outside. She confirmed he slept poorly, with less than 3 hours of sleep per night. VA records from 2007 through 2009 revealed that the Veteran was in receipt of regular treatment from VA social work and psychiatry, with treatment that included individual therapy counseling, as well as medication. Generally the findings and complaints reported in the psychiatry notes from this time period included trouble sleeping more than 3 to 4 hours per night, with present problem to include relationship problems with his wife. Also reported in the VA notes including from social work/psychotherapy were complaints of flashbacks, intrusive thoughts and nightmares. Mental status examinations generally showed him to be somewhat anxious and depressed, but no enough to warrant hospitalization. He repeatedly showed good affect with no suicidal or homicidal ideations. He was also described as being oriented to all spheres, with speech normal, appropriate dress, grooming and hygiene, affect full, thought content logical and goal directed with no evidence of psychosis, and at least fair insight and judgment in the various mental status examinations in the various VA psychiatry and social work records from 2007 to 2009. These records did reveal that in a December 2007 social work record, the Veteran reported his major problem as poor sleep, but he also endorsed conflicts with others in his family as well as his supervisor. He also reported believing he heard people milling around when he is at home, but no one is there. He denied visual hallucinations and also did not appear delusional. When further pressed, he admitted to marital discord, which was somewhat improved since April 2007. The marital conflicts seemed centered around issues with his wife's work schedule and differences in parenting approaches. The therapy records from 2008 appeared centered around continuing relationship problems with his wife, with a September 2008 record noting that the Veteran reacted to a public argument between them by breaking a shed door when he returned home. In October 2008 he provided more details about his marital conflicts indicating that an indiscretion by him earlier in the year continued to fuel conflict. The records also continued to document his inability to work as a corrections officer due to his PTSD symptoms, requiring he change to a position in maintenance. The records also document that the Veteran was repeatedly recommended to attend a VA program called "PTSD University" but persisted in not attending, with a February 2009 record indicating that he was unable to do so because it would conflict with work. By February 2009, his marital situation was described as having been stable and that he had been able to adequately control his PTSD symptoms with learned skills and medications, with medication compliance reported. With the exception of a GAF score of 60 assigned in December 2007, the Veteran's GAF score consistently was reported as 50 in the VA records from 2008 through February 2009 addressing his PTSD symptoms. The Axis I diagnosis was consistently limited to PTSD, with no Axis II diagnosis given in these records. In January 2009 the Veteran underwent a neuropsychiatric evaluation of his current levels of neurocognitive functioning given an apparent history of traumatic brain injury (TBI) resulting from a fall and head injury while in a truck. He reported symptoms that included increased forgetfulness and decreased attention and concentration. Since he returned home, he and his wife noted several changes including increases in anger, irritability, preoccupation with orderliness and distractibility. He also endorsed significant difficulty falling asleep at night and had nightmares a few times a week. His sleep and concentration were disrupted at times by headaches and/or racing thoughts. He and his wife also reported significant difficulty remembering everyday things, such as keeping track of bills, returning calls or remembering familiar people's names. The Veteran described these problems of forgetfulness, sleep issues, irritability, and poor frustration tolerance as very severe problems. He described poor concentration, difficulty making decisions, slowed thinking, fatigue and feeling anxious as severe problems. He described feeling depressed, sensitivity to noise and appetite loss as moderate problems. Mental status examination in the January 2009 neuropsychiatric examination was like others shown in the VA psychiatric and social work records, with the Veteran alert and oriented, with appropriate dress and grooming. His speech was fluent and intelligent, with no evidence of word finding difficulties or paraphrasic errors. His mood was "flat" and his depression and anxiety levels were both rated as a 4/10. He had no evidence of a thought disorder or perceptual disturbance. There were no hallucinations or delusions evident. He also had no suicidal or homicidal ideations. He was administered cognitive and psychiatric tests with the scoring deemed to meet the criteria for a diagnosis of PTSD. The Veteran's level and pattern of performance was deemed to not be consistent with mild TBI. Given his clinical history it seemed more likely that his current difficulties are related to his PTSD symptoms. VA treatment records after February 2009 through 2010 dealt with other medical problems besides his PTSD. Likewise records from 2011 dealt primarily with other medical problems. However in pertinent part, medical notes from July 2009 and April 2011 addressing cognitive issues thought to potentially be due to TBI advised that the Veteran use a daily organizer and calendar, allow extra time to learn material break learning material into smaller portions to be rehearsed, and carry a notebook to write down important information. In April 2011 he was described as sleeping better which helped more than anything, and overall felt that he was improving. A depression screen and alcohol screen in an April 2011 nursing note was negative. A September 2011 Lipid profile described the Veteran as working a lot and was active in building a pole barn. The report of a November 2011 VA examination diagnosed PTSD with no other Axis I or Axis II diagnoses made. His GAF score was 68. He was described as doing well in his job and with his family relationship strong, although occasionally strained by his PTSD symptoms. He had some social activities which are moderately decreased due to social discomfort and avoidance. Treatment records and overall psychosocial function suggested some improvement and stabilization. He was described as also having TBI although it was not possible to differentiate symptoms attributable to each diagnosis. He was described as having occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication. The clinical findings to support this diagnosis and opinion revealed the Veteran to have a good relationship with his family members, and a 17 year marriage. He reported a tendency to isolate and be angry which has strained his marriage. This has improved over time as his wife learned more about PTSD. Generally he described a strong supportive relationship with wife and teenage children. He was close friends with a neighbor he saw almost daily, with other friendships generally limited to phone calls and internet. He attended church weekly and regularly attended his children's sporting events. He belonged to a Masonic lodge and attended monthly meetings. He was working at a nuclear plant since June 2009 involved in chemical waste removal. His job was less stressful than his previous one. He had no problems with supervisors or coworkers. He used about 70 hours of leave in the past year with some due to intense periods of anxiety. He had no history of hospital admissions. The examiner reviewed the findings from prior examinations and records noting the diagnosis of PTSD and possible TBI for which he saw a neuropsychologist in January 2009, although his overall presentation was not consistent with TBI. The examiner confirmed that the Veteran currently meets the criteria for PTSD based on a checklist. His history was noted to be significant for having an incident about a year and a half ago when he destroyed a barn door on his property out of anger. The current symptoms reported in the November 2011 VA examination included anxiety, suspiciousness, panic attacks occurring weekly or less often, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. He also had difficulty in adapting to stressful circumstances including work or worklike settings. He had no other symptoms attributable to PTSD. He was deemed to be capable of managing his finances. Test results were described as his having a profile consistent with individuals who are anxious and jumpy with problems sleeping and elevated somatic complaints. Additionally individuals fitting his profile were described as suspicious and sensitive to the actions of others, resulting in them keeping emotional distance. This was common in people with PTSD. An addendum from later in November 2011 confirmed review of the claims folder. After a thorough review of the evidence, the Board finds that the VA examination reports, VA treatment records, and lay statements indicate that the impact of the Veteran's PTSD on his social and industrial functioning is most congruent with the currently-assigned 50 percent evaluation. Although the Veteran does not have all the symptomatology consistent with the assignment of a 50 percent rating, the Board finds that the impact of the Veteran's PTSD on his social and occupational functioning sufficiently approximates the degree of impairment contemplated by a 50 percent rating. See 38 C.F.R. § 4.7 (2012). Criteria for the assignment of a 50 percent rating that have been met or approximated include difficulty in establishing and maintaining effective work and social relationships, disturbances of motivation and mood, and impairment of short-term memory. In making this determination, the Board has also considered the Veteran's GAF scores of record. During the appeal period, the Veteran has been assigned GAF scores ranging from 50 to 60, with the exception of the highest rating of 68 assigned in the November 2011 VA examination. Most consistently, his scores have generally been assigned a 50. Evaluating these scores in conjunction with the above-discussed treatment and examination notes, the Board finds that these GAF scores are consistent with a 50 percent rating of the Veteran's PTSD. The Board acknowledges that the record contains evidence of certain elements of a 70 percent rating, but the Board concludes that the Veteran's overall disability picture is not most congruent with a 70 percent rating. Specifically, the Board notes that the Veteran has expressed homicidal ideation: for example, the Veteran's August 2006 VA social work and psychiatric reports indicated that the Veteran had a strong reaction to a fellow guardsman's behavior towards him that was described as homicidal in nature, couched in terms as "battlemind state." Additionally, the Veteran's and his wife's reports of periodic irritability and anger with occasional destruction of items, and the records documenting such behaviors, arguably suggest that the Veteran has occasional impaired impulse control. The record does not demonstrate, however, that the Veteran suffers from obsessional rituals that interfere with routine activities, intermittently illogical, obscure, or irrelevant speech, or near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. The Veteran does not suffer from spatial disorientation, and he does not neglect his personal appearance or hygiene. The Veteran is not unable to establish and maintain effective relationships. To the contrary, the records from 2008 and 2009 indicate that while there was some marital and family conflict, the Veteran was able to adequately address such problems to the point that by the time of February 2009, his marital situation was described as having been stable and that he had been able to adequately control his PTSD symptoms with learned skills and medications. The November 2011 examination indicated that the Veteran reported having good relationships with his wife and other family members, with the marital strain caused by PTSD symptoms said to have improved over time as his wife learned more about PTSD. Additionally, the evidence reflects the Veteran enjoyed good social relationships with friends and participated in activities with church and fraternal organizations. Occupationally, while he is historically shown to have had to change job positions from a higher pressure job of a correctional officer to a lower pressure maintenance position, and also is shown to have used sick and vacation leave to address his symptoms, he nonetheless has been able to maintain gainful employment throughout the pendency of his appeal. Most recently, his November 2011 examination revealed no problems with supervisors and coworkers at his current job. For these reasons, the Board finds that while the record contains a few elements of a 70 percent rating, a 70 percent rating of the Veteran's PTSD is not appropriate in the instant case. With respect to a 100 percent disability rating, the record does not indicate that the Veteran suffers from total occupational and social impairment. To the contrary, as noted above, the Veteran enjoys good relationships with friends and family members. The record does not demonstrate any gross impairment in thought processes or communication, grossly inappropriate behavior, or the persistent danger of hurting himself or others. The Veteran has not demonstrated an intermittent inability to perform the activities of daily living, including maintenance of minimal personal hygiene. The record reveals no disorientation to time and place, and the Veteran has not shown memory loss for his occupation, his own name, or those of his close relatives. While the Veteran's VA treatment records suggest that the Veteran may have experienced both auditory hallucinations (manifested as hypersensitive hearing) and paranoid ideations (generally about others harming him), the record does not indicate that such hallucinations or paranoid ideations have been persistent; the record is additionally negative for any delusions. In light of the foregoing, the Board concludes that while the Veteran demonstrates a few of the criteria for a 70 percent disability rating and arguably one of the criteria for a 100 percent disability rating, the evidence of record does not show that the Veteran's overall level of severity more closely approximates the criteria for a 70 or 100 percent disability rating than a 50 percent rating. See 38 C.F.R. § 4.130 (2012). Moreover, there are no other factors which would lead the Board to conclude that a 70 or 100 percent disability rating is warranted. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (noting that the specified factors for each incremental rating are examples rather than requirements for a particular rating; analysis should not be limited solely to whether the veteran exhibited the symptoms listed in the rating scheme.) A review of the medical evidence indicates that the Veteran's psychiatric symptomatology centers on his irritability/anger, nightmares and sleep problems, hypervigilance, disturbances of mood and motivation, and difficulty establishing work and social relationships. These symptoms are most congruent with the assigned 50 percent disability rating. The Board finds that there is no basis for a staged rating of the Veteran's PTSD because the Veteran's disability picture is essentially uniform throughout the appeal period. See Fenderson and Hart, supra. Extra-Schedular Considerations In addition, the Board has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In Thun v. Peake, the Court set forth a three-step inquiry to determine a veteran's entitlement to an extra-schedular rating. 22 Vet. App. 111 (2008). 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 does not contemplate the Veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran's 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. In this case, it is not necessary to go any further than the first step of the Thun analysis. The rating criteria are not inadequate. Higher ratings are available for PTSD, but, as discussed above, the Veteran does not meet those criteria. It does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplate by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extra-schedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extra-schedular consideration is moot. See Thun, supra. ORDER Entitlement to an increased initial rating for PTSD is denied. ____________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs