Citation Nr: 1302935 Decision Date: 01/25/13 Archive Date: 01/31/13 DOCKET NO. 05-34 304 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an initial disability rating in excess of 70 percent from December 30, 2008 for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from March 1988 to March 1992 and from November 1993 to January 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating and Decision Review Officer decisions of the Waco, Texas Department of Veterans Affairs (VA) Regional Office (RO). The claim for service connection for PTSD was denied by the RO in a January 2005 rating decision and the Veteran filed a notice of disagreement (NOD) in March 2005. In a July 2005 Decision Review Officer decision, the RO awarded service connection for PTSD, assigning a 30 percent disability rating, effective January 28, 2004. The Veteran filed an NOD with respect to the evaluation of his PTSD in July 2005. The Veteran testified at a hearing before the undersigned in January 2009. A transcript of that hearing has been associated with the claims file. In May 2009 and May 2010, the Board, in part, remanded this claim to the RO for additional action. In an October 2011 rating decision, the RO awarded the Veteran a 70 percent disability rating for PTSD, effective December 30, 2008. In January 2011 and October 2012, the Board, in part, again remanded this claim to the RO for additional action. Also in October 2012, the Board granted an initial 70 percent disability rating for PTSD for the period from January 28, 2004 to December 29, 2008 and assigned an initial 10 percent disability rating for leishmaniasis from August 1, 2005. As this decision was final when issued and the Veteran's has not filed a notice of appeal on these claims, they are no longer in appellate consideration. 38 U.S.C.A. § 7104 (2012). A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records. A supplemental SOC (SSOC) was issued in December 2012, which addressed this additional evidence. In its prior remands, the Board referred raised claims to the RO for appropriate action, including whether new and material evidence has been received to reopen a claim for service connection for tinnitus and entitlement to an increased evaluation for hypertension. These claims were adjudicated by the RO in February 2011 and the Veteran has not filed an NOD with respect to this decision. The Board's October 2012 decision and remand also found that the Veteran also raised claims for compensation for erectile dysfunction and sleep apnea secondary to PTSD in July 2012 and referred these matters to the RO for appropriate action. As the RO has not yet taken action in response to the referrals for erectile dysfunction and sleep apnea, the Board again REFERS these matters to the RO for appropriate action. FINDING OF FACT From December 30, 2008, the Veteran's PTSD symptoms have been productive of moderate to severe symptoms causing occupational and social impairment with deficiencies in most areas, including work, family relations, mood and thinking. CONCLUSION OF LAW The criteria for entitlement to an initial disability rating in excess of 70 percent from December 30, 2008 for PTSD are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board will discuss the relevant law which it is required to apply. This includes statutes published in Title 38, United States Code ("38 U.S.C.A."); regulations published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet.App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet.App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet.App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). The Veterans Claims Assistance Act (VCAA) Under the VCAA, VA must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was provided notice of the VCAA in July 2004. An additional VCAA letter was sent in January 2011. The VCAA letters indicated the types of information and evidence necessary to substantiate the claim, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The Veteran also received notice in January 2011, pertaining to the downstream disability rating and effective date elements of his claim, with subsequent readjudication in March 2012 and October 2012 SSOCs. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Mayfield and Pelegrini, both supra. Service connection for PTSD has been established and an initial rating for this condition has been assigned. The claim has therefore been substantiated. See Dingess v. Nicholson, 19 Vet. App. at 490-491. Notice under the VCAA is no longer required as to this matter, because the purpose for which such notice was intended to serve has been fulfilled. Id. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claim in this Board decision. All relevant evidence necessary for an equitable resolution of the issue on appeal has been identified and obtained, to the extent possible. The evidence of record includes VA outpatient treatment reports, VA examinations, VA examination addendums, and statements and testimony from the Veteran and his representative. The August 2009 and December 2009 VA examination reports and addendums reflect that the examiners reviewed the Veteran's past medical history, documented his current medical condition, and rendered appropriate diagnoses and addendums consistent with the remainder of the evidence of record, and with supporting rationale. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Consequently, the medical examinations and addendums are adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). This case was previously remanded by the Board in October 2012 to readjudicate the Veteran's claim based on additional VA treatment records associated with the claims, for which the Veteran did not waive his right of initial RO consideration. As an SSOC was issued in December 2012 addressing this additional evidence, the development requested by the Board's October 2012 remand has now been satisfactorily completed and substantially complied with respect to the Veteran's PTSD claim. See Stegall, 11 Vet. App. 268 (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). A claim for a total disability rating based upon individual unemployability (TDIU), has not been raised. The evidence does not demonstrate, and the Veteran does not allege, that his PTSD causes unemployability or marginal employment and he admits he is working full-time. A claim for entitlement to a TDIU rating will not be considered as part of the determination of the claims on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. VA has obtained, or made reasonable efforts to obtain, all evidence that might be relevant to the issues on appeal, and that VA has satisfied the duty to assist. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2012). The Merits of the Appeal Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in the disorder, it is necessary to consider the complete medical history of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When, as here, the Veteran is requesting an increased rating for an established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the most recent examination is not necessarily and always controlling. VA must consider not only to the evidence as a whole but to both the recency and adequacy of examinations. See Powell v, West, 13 Vet. App. 31, 35 (1999). Where the question for consideration is the propriety of the initial evaluation assigned after the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged ratings" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found - this practice is known as "staged ratings." See id. at 126. From December 30, 2008, the Veteran has been assigned a 70 percent evaluation for PTSD under 38 C.F.R. § 4.130, Diagnostic Code 9411, which is evaluated under the general rating formula for mental disorders. Under this general rating formula, 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); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 100 percent rating is warranted 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; memory loss for names of close relatives, own occupation or own name. See id. The symptoms recited in the criteria in the rating schedule for evaluating 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 rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). A GAF score ranging from 61 to 70 indicates some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, (e.g. occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score ranging from 51 to 60 indicates 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 peer or coworkers). A GAF score of 41 to 50 indicates serious symptoms and serious impairment in social, occupational, or school functioning (e.g., no friends), while a GAF score of 31 to 40 indicates 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 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). See Diagnostic and Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM-IV). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Accordingly, GAF scores do not automatically equate to any particular percentage in the Rating Schedule. Rather, they are but one factor to be considered in conjunction with all the other evidence of record. On December 30, 2008, the Veteran was treated at VA for a rash on his legs and blurry vision, and also reported feeling depressed with recent suicidal ideation. In a December 30, 2008 VA outpatient treatment report, the Veteran complained of symptoms including nightmares, irritability, lost interest and trust and vivid images of his time in Iraq, which had increased in the past year and a half. He then reported experiencing various symptoms including: weekly nightmares; sleep difficulty; poor interest; apathy; worthlessness; insomnia; low energy/fatigue; weight gain/loss; poor appetite; hopelessness, suicidal ideations; emotional lability; psychomotor retardation/irritability; poor memory; lack of concentration; feeling edgy; sweating; intrusive thoughts; images of past trauma; nightmares; physiological/psychological distress; emotional numbness; detachment; diminished interest; anger; and increased startle response. The Veteran reportedly discontinued his psychiatric medications which were prescribed for depression, anxiety and sleep. He also reported having two therapy sessions. No suicide attempts were reported. A mental status evaluation revealed the Veteran was casually dressed and neatly groomed, his speech was clear, logical and goal oriented, his mood was sad, his affect was depressed and angry and he was oriented in all four spheres. His thought content was absent of auditory or visual hallucinations, delusion, homicidal ideations or assaultive thoughts, although he did report suicidal ideations. A provisional diagnosis of PTSD and depression disorder was provided and the Veteran was assigned a GAF score of 60. He was noted to have concerns that were consistent with PTSD and had briefly attempted treatment through counseling and medication approximately four years earlier but discontinued treatment after a few months. The Veteran wished to have treatment and was referred to the PTSD clinical team (PCT) for follow up. During a January 2009 Travel Board hearing, the Veteran testified that his PTSD symptoms included sleep difficulty, nightmares, depression, suicidal thoughts, anxiety, panic attacks, flashbacks, memory problems, social isolation, anger and rage. In terms of obsessional rituals, the Veteran reported having to go back home after leaving to recheck the locks. He also reported that he was on medication for depression, anxiety, panic attacks and sleeping but he stopped taking medications because he was getting sick of them and he felt they were not helping. The Veteran testified that he was estranged from his daughter. He stated that he was currently working full-time as an Army contractor, specifically as an equipment inspector. The Veteran reported he had some memory difficulty on the job in the last couple of years. He lived with his wife and two of his children. The Veteran reported that his children make sure he is "okay" before they have a conversation with him and that he has "snapped" at his wife more and drank more than he normally did. At an August 2009 VA examination, the Veteran reported having no hospitalizations for a mental disorder. He also reported that he had been married for three years with two step sons and that he had one daughter and a grandson with whom he had no contact. The Veteran stated that he had withdrawn quite a bit from his family over the past few years; he felt closest to his youngest son; and he withdrew from his wife often. He isolated himself at home and had few friends in the area. His reported degree and quality of social relationships was poor and he was isolated most of the time, even from his family. No history of suicide attempts, violence or assaultiveness was reported. The Veteran's loss of his brother, who was also his best friend, was his biggest recent stressor and caused him to isolate even more. No issues with alcohol or substance use were reported. A psychiatric examination revealed that the Veteran was neatly groomed and casually dressed, tense and irritable with a flat affect and a depressed mood. His attention was intact and he was oriented to person, place and time. Thought processes and content were unremarkable. No delusions were noted. The Veteran understood the outcome of his behavior, was found to be of average intelligence and understood that he had a problem. He reported having sleep impairment and nightmares. No hallucinations or inappropriate behavior was noted. The Veteran interpreted proverbs appropriately. No obsessive or ritualistic behavior was found. The Veteran reported having panic attacks every time he saw an "18- wheeler," which could be up to several times a week. No homicidal thoughts were reported. The Veteran admitted to having past suicidal thoughts, however, he stated he would not do so as he had a strong attachment to his children and wanted to be around to care for them. Impulse control was good, no history of violence was noted and the Veteran was found to be able to maintain minimum personal hygiene. Remote, recent and immediate memories were found to be normal. PTSD symptoms of persistent reexperiencing of the traumatic event were noted to include recurrent distressing dreams and psychological distress and physiological reactivity upon exposure to external or internal cues resembling the traumatic event. In addition, PTSD symptoms of persistent avoidance of stimuli associated with trauma and numbing of general responsiveness were demonstrated by avoidance, diminished interest, detachment or estrangement from others, a restricted range of affect and a sense of a foreshortened future. PTSD symptoms of persistent, increased arousal were exemplified by difficulty sleeping, irritability or outbursts of anger. Behavioral, cognitive, social, affective or somatic changes which were attributed to stress included isolation, conflicts with supervisors at work, easy agitation, anger, no leisure time pursuits, a flat affect and depression. The Veteran reported being employed as a government contractor and worked as an inspector full-time. Problems related to occupational functioning included decreased concentration, difficulty following instructions and poor social interaction. He was diagnosed with PTSD and assigned a GAF score of 50, encompassing the past two years. The examiner noted that the Veteran isolated himself "most all of the time" due to distrust, anger and an inability to relate his problems to others. He reportedly tried medications and therapy for PTSD symptoms without good results. The examiner noted that, the Veteran stated several times throughout the interview that he felt he could not be helped and would be plagued all his life with these symptoms; he had occasional suicidal thoughts but that he would never act on his thoughts due to his strong desire to be with his children. The death of the Veteran's brother, mother and father were found to have compounded his problems with PTSD, particularly his depression and anxiety. He was noted to use alcohol occasionally but stated it was not a problem. The prognosis for improvement was guarded and the supervising psychiatrist spoke with the Veteran about returning to treatment, which he was considering. He was not found to have total occupational and social impairment due to PTSD signs and symptoms, however, the examiners observed that his PTSD signs and symptoms resulted in deficiencies in most areas including thinking, family relations, work and mood. VA outpatient treatment reports from December 2009 reflect that the Veteran's reported PTSD symptoms included: depression; anxiety; isolation; hopelessness; helplessness; loss of interest; anger; irritability; suicidal ideation without intent or plan; poor concentration; repetitive thoughts; feelings of guilt; avoidance of others; anger outbursts; memory problems; avoidance of responsibilities; momentary thoughts of causing harm to others; feelings of regret; grief and sense of loss; hypervigilance for threats; some auditory hallucinations; nightmares; flashbacks; and sleep problems. He reported having a distant relationship with his wife and children due to loss of interest and isolation. A mental status evaluation revealed the Veteran's appearance was within normal limits, he was cooperative and oriented in all three spheres. His speech was normal. His mood in the past 30 days included: depression; irritability; restlessness; withdrawal; anger; sadness; agitation; worry; jumpiness; fear; impatience; argumentativeness; tearfulness; distractibility; and lack of motivation. His current levels of depression and anxiety were rated as an eight and nine out of 10 in severity. He had normal cognition, logical and goal directed thought processes, fair judgment and was not found to be a danger to himself or to others. While the Veteran reported suicidal thoughts, including approximately three weeks previously, he had no current plan or intent and stated that his relationship with his son prevented him from acting on his thoughts. He also reported having thoughts of hurting others when he was angry with no current plan or intent and no reported homicidal ideation. The Veteran was diagnosed with PTSD and depression and was assessed with a GAF score of 50. He was evaluated as a low to moderate suicide risk, meaning his potential for suicidal behavior was low. During a December 2009 VA examination, the Veteran noted that he underwent individual psychotherapy and he was currently on medication for PTSD, including an anti-depressant. His first therapy session was the day before this examination and he had just been prescribed psychiatric medication after three years of not taking any. The Veteran stated he had been married for three years and had two children from his wife's previous relationship and from whom he was isolated. The Veteran reported having two children from a previous marriage but was not very close with his son and had not spoken to his daughter in years. He noted his relationship with his wife could be better. The Veteran reported having two friends he talked with from time to time and that he had lost contact with many Army buddies. He spent his time primarily watching television and described a loss of interest in former activities. The Veteran also reported having a suicide attempt eight months previously when he had a few pills but thought about his son and did not take them. His reported PTSD symptoms consisted of depression, suicidal ideation, social isolation and loss of interest. No violence of assaultiveness was reported. He also relied on alcohol to elevate his mood. A psychiatric evaluation revealed the Veteran was clean and cooperative with intact attention and full orientation to person place and time. His speech was noted as soft or whispered. He had a full affect, a depressed mood and an unremarkable thought process. His thought content was noted to include suicidal ideation and guilt. No delusions were found. The Veteran understood the outcome of his behavior and that he had a problem. Sleep difficulty was noted with nightmares. He reported auditory hallucinations that were not persistent. Inappropriate behavior included irritability and isolation. Obsessive or ritualistic behavior was noted to include checking the locks during the night and returning home to check the locks after leaving. The Veteran reported having panic attacks. No homicidal thoughts were found, although daily thoughts of suicide were noted. He had fair impulse control and no history of violence as he isolated himself to avoid anger. He was able to maintain a minimum personal hygiene. The examiner noted no problems with activities of daily living. The Veteran's remote memory was normal and his recent memory and immediate memory were mildly impaired. PTSD symptoms of persistent reexperiencing of the traumatic event were demonstrated by recurrent distressing dreams of the event. Persistent avoidance of stimuli associated with trauma and numbing of general responsiveness was exemplified by the Veteran's diminished interest or participation in significant activities, detachment or estrangement from others, restricted range of affect and a sense of foreshortened future. Persistent symptoms of increased arousal included difficulty falling or staying asleep, irritability or outbursts of anger and hypervigilance. The Veteran reported symptoms had worsened recently. The identified behavioral, cognitive, social, affective, or somatic changes which were attributed to stress exposure included the inability to joke with others, intrusive thoughts taking over his life, self hatred, helplessness, lost trust of anyone, unhappiness, guilt, and he felt punished for what he did in Iraq. The Veteran's usual occupation was a mechanic and he was then employed full-time. The Veteran reported having time lost from work during the last 12 month period due to medical and mental health appointments. Problems related to occupational functioning included increased absenteeism, poor social interaction, and irritability. The Veteran was diagnosed with severe PTSD and major depressive disorder and assigned a GAF score 50. The examiner noted that the Veteran's changes in functional status and quality of life since the last examination included employment performance, family role functioning, social and interpersonal relationships and recreation/leisure pursuits. The Veteran reported conflict at work and social isolation with a few friends. He described isolating from everyone including family and was estranged from his daughter. He reported having a loss of interest in activities. The examiner noted the symptoms were classic symptoms of PTSD and based on the Veteran's self report, it seemed clear that is problems began after he returned from war. The examiner noted that, although major depression could account or some of the functional impairment, it was more likely than not that depression was secondary to combat related trauma. The examiner found that the Veteran was not fully engaged in treatment due to an inability to take off from work and, per his own report, "having to feed [his] family." The Veteran was not found to have total occupational and social impairment due to PTSD signs and symptoms, however, it was found that his PTSD signs and symptoms resulted in deficiencies in most areas including judgment, thinking, family relations, work and mood. Finally, the examiner noted that the Veteran had reported a worsening of symptoms and frequent suicide ideation and was open to treatment and even hospitalization but felt blocked because of his need to work. Subsequent VA outpatient treatment reports through November 2012 reflect that the Veteran's PTSD symptoms consisted of: depression; anxiety; irritability; adequate hygiene; nightmares; sleep difficulty; helplessness and hopelessness; rapid and angry to normal speech; tangential to logical and goal directed thought processes; no thought disorder; no suicidal or homicidal ideation with reports of past suicidal ideation; thoughts of self harm with no plan or ideation because his family needed him to help support the household financially; fair insight and judgment; intact cognition and intact memory. In June 2010, the Veteran became aggressive with a VA treatment provider and complained of depression but admitted to noncompliance with his medications and he refused treatment with the mental health clinic. At that time he became disrespectful, abusive and aggressive with the VA treatment provider and the interview was interrupted rather than having security called. He was diagnosed with depression and anxiety. A GAF of 60 was also assigned in June 2010. Throughout this period, the Veteran was assessed to be a low suicide risk with potential for suicidal behavior being low and he was not judged to be at a significant risk of harm. Also during this period, he continued to refuse mental health treatment clinic and was noncompliant with his psychiatric medications. The Veteran's PTSD does not warrant an initial disability rating in excess of 70 percent at any time throughout the duration of the appeal. The probative evidence of record describes the Veteran's PTSD as being reflective of occupational and social impairment with deficiencies in most areas, including work, family relations, judgment, thinking and mood so as to more nearly approximate the 70 percent criteria, which is currently assigned. The symptoms listed under the 100 percent evaluation criteria are examples of the types and degree of symptoms that would warrant such evaluation, and that the Veteran need not have all of these particular symptoms in order to warrant a 100 percent evaluation. See Mauerhan, 16 Vet. App. 436. However, for the reasons discussed below, the criteria described under the 100 percent evaluation reflect a more serious disability, resulting in total occupational and social impairment, than is demonstrated by the Veteran's PTSD. The record reflects the Veteran's symptoms are representative of severe occupational and social impairment and include suicidal ideation, near continuous panic and depression, impaired impulse control and difficulty in adapting to stressful environments, however, these symptoms are all present within the 70 percent rating criteria. The Veteran remains both employed and cognizant of his disability and familial relations. There can be no doubt that PTSD symptoms have a marked effect on his social functioning as evidenced by periodic hallucinations, suicidal ideation, one report of momentary thought of harm toward others in December 2009. However, he Veteran is not shown to be "totally" impaired such that he is incapable of working or relating to others. On examinations, he has been shown to be responsive to questioning; aware of his surroundings, familial relations (albeit also aware of the difficulties in relating to family members); able to care for himself; and not disoriented. Although hallucinations had been reported on occasion, the Veteran also denied having hallucination and delusions in various mental status evaluations during the period of the appeal, and therefore these have not been persistent. See VA outpatient treatment reports from December 2008 to November 2012. Although the Veteran had reported suicidal ideation and thoughts of self harm throughout the duration of the appeal, along with these reports he also continually reported that he had no current plan or intent, that his relationship with his son prevented him from acting on his thoughts and that he had no current plan or intent because his family needed him to help support the household financially. Likewise, although he reported thoughts of hurting others when he was angry in one instance, in December 2009, he also admitted having no current plan or intent and the medical evidence of record demonstrates that he had no reported homicidal ideation at any time. In this regard, he is aware both of his illness and the likely consequences for any homicidal or suicidal actions. Throughout the duration of the appeal, the Veteran had been assessed as a low to moderate suicide risk, meaning his potential for suicidal behavior was low, he was judged not to be at significant risk for self harm, and was at an increased risk of suicide but not acutely dangerous to himself. In fact, he was only assessed as a moderate risk of suicide on one occasion, in December 2009, and was later assessed the same day as being at a low risk of suicide. Therefore, there is no evidence indicating that the Veteran is a persistent harm to himself or to others. Finally, the mild impairment of recent and immediate memory noted in the December 2009 VA examination is not demonstrative of a memory loss for names of close relatives, his own occupation or his own name. While the Veteran need not have all of these particular symptoms in order to warrant a 100 percent evaluation per the Court's finding in Mauerhan, his PTSD symptomatology does not demonstrate total social and occupational impairment, as he has been able to work full-time and to maintain effective social relationships with his family and two friends. See Mauerhan, 16 Vet. App. 436. The evidence of record demonstrates that the Veteran is isolated and withdrawn from his family; however, he continues to maintain relationships with his wife, her two children and two of his friends. The Veteran also reported that his relationship with his son prevented him from acting on his thoughts of self harm and that he did not act on his thoughts of self harm as his family needed him to help support the household financially. In addition, the Veteran continued to work full-time and reported that he missed work only for his VA treatment appointments, however, the medical evidence of record reflects that he only sought mental health treatment a few times year, at most, since December 30, 2008 and he continually refused treatment with the mental health clinic, psychotherapy or any psychiatric/psychological evaluation. Furthermore, while the Veteran's GAF scores ranged from 50 to 60, evaluations are not assigned based solely upon GAF scores, and the symptomatology described in the record fails to more nearly approximate the criteria for a 100 percent rating at any point during the course of the appeal. Therefore, the probative evidence of record does not demonstrate the Veteran's PTSD has been productive of total occupational and social impairment so as to more nearly approximate the criteria for a 100 percent disability rating at any time since December 30, 2008. See id. In reaching the above conclusions, the Board has not overlooked the lay statements and testimony by the Veteran with regard to the severity of his service-connected PTSD. The Veteran is competent to report on factual matters of which he had firsthand knowledge and thus, he is competent to report his current symptomatology as it pertains to his PTSD. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, with respect to the Rating Schedule, where the criteria set forth therein require medical expertise which the Veteran and his spouse have not been shown to have or where these types of findings are not readily observable by a lay person, the Board has accorded greater probative weight to objective medical findings and opinions provided by the Veteran's treatment reports and his VA examination reports. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) ("[t]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . the credibility and weight to be attached to these opinions [are] within the province of the adjudicator."). Thus, the Veteran's reports with respect to experiencing symptoms of PTSD have been considered in evaluating his disability rating in this decision. The Veteran's PTSD does not warrant an initial disability rating in excess of 70 percent. The record does not show persistent symptoms that equal or more nearly approximate the criteria for an evaluation in excess of 70 percent at any time since December 30, 2008. See Fenderson, 12 Vet. App. at 125-26. The Veteran's disability has been no more than 70 percent disabling since the effective date of his award, so his rating cannot be "staged" because this represents his greatest level of functional impairment attributable to this condition. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. 38 C.F.R. § 4.3; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The benefit sought on appeal is accordingly denied. Extraschedular Consideration At no point since December 30, 2008 has the disability on appeal been shown to be so exceptional or unusual as to warrant the assignment of a rating, higher than that assigned above, on an extra-schedular basis. See 38 C.F.R. § 3.321. The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993); see also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedural Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, 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 this 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 rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. The schedular criteria are adequate to rate the disability under consideration. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than those assigned based on more significant functional impairment. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial disability rating in excess of 70 percent from December 30, 2008 for PTSD is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs