Citation Nr: 1303569 Decision Date: 02/01/13 Archive Date: 02/08/13 DOCKET NO. 10-07 032 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an initial disability evaluation in excess of 70 percent for PTSD prior to May 15, 2012. ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from December 1973 to December 1975. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating determination of the Houston, Texas, Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for PTSD and assigned a 50 percent disability evaluation with an effective date of January 27, 2006. Thereafter, the Veteran appealed both the assigned disability evaluation and the effective date. In an April 2012 decision, the Board assigned an earlier effective date for the grant of PTSD of July 22, 2002, which was the full benefit sought on appeal as to this issue, and remanded the initial evaluation issue to the RO further development, to include a VA examination. The requested examination was performed in May 2012. Following the May 2012 examination, the Appeals Management Center (AMC), acting on behalf of the RO, in a September 2012 rating determination, increased the Veteran's initial disability evaluation from 50 to 70 percent effective the date of the grant of service connection and assigned a 100 percent disability evaluation for PTSD from May 15, 2012. As a result of the RO/AMC actions in this case, the Board has listed the issue as such on the title page of this decision. FINDINGS OF FACT 1. Prior to July 20, 2006, the Veteran's PTSD did not result in 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; nor did it result in total social and industrial impairment. 2. From July 20, 2006, the Veteran's PTSD symptoms resulted in persistent delusions/hallucinations; grossly inappropriate behavior; and persistent danger of hurting self or others. CONCLUSIONS OF LAW 1. The criteria for an initial disability evaluation in excess of 70 percent for PTSD prior to July 20, 2006, have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a 100 percent disability evaluation for PTSD from July 20, 2006, have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA has a duty to notify a veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. In order to meet the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must (1) inform the veteran about the information and evidence necessary to substantiate the claim; (2) inform the veteran about the information and evidence that VA will seek to provide; and (3) inform the veteran about the information and evidence the veteran is expected to provide. VCAA notice should be provided to a veteran before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. The United States Court of Appeals for Veterans Claims (Court) held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include (1) the veteran's status; (2) the existence of a disability; (3) a connection between the veteran's service and the disability; (4) the degree of disability; and (5) the effective date of the disability. The Court held that, upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim, and to provide the veteran with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. This notice must also inform the veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. In this case, VCAA notice letters sent in May and June 2006 satisfied the provisions of 38 U.S.C.A. § 5103(a). In these letters, VA informed the Veteran about the information and evidence not of record that was necessary to substantiate the claim; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and the information on disability ratings and effective dates required by Dingess. Moreover, because the Veteran's appeal arises from the Veteran's disagreement with the initial rating following the grant of service connection for PTSD, no additional notice is required. The Court and the United States Court of Appeals for the Federal Circuit (Federal Circuit) have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement). Nevertheless, the Board also finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, VA treatment records, VA examination reports, and lay evidence. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c). No additional pertinent evidence has been identified by the claimant. The Veteran was afforded VA examinations in July 2006 and May 2012 regarding his PTSD. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examinations to be adequate for rating purposes. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and by being afforded the opportunity to appear at a hearing if so desired. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Evaluation Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). In view of the number of atypical instances 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, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The General Formula for Rating Mental Disorders, Diagnostic Code 9411, provides that a 70 percent evaluation is assigned 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 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 worklike setting); inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent evaluation is assigned 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 or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The symptoms cited above for the 70 percent and 100 percent ratings follow the phrase "such symptoms as" which indicates that the symptoms after that phrase 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. Accordingly, the Board is not required to find the presence of all, most, or even some, of the enumerated symptoms for any particular rating. The list of symptoms merely provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. The Board must consider all symptoms of the veteran's condition which affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 441-443 (2002). The Global Assessment of Function (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM), 32 (4th ed.) (1994) (DSM IV); 38 C.F.R. §§ 4.125, 4.130 (2011). GAF scores between 71 to 80 is indicative that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more that slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). Scores ranging between 61 to 70 reflect 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, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect 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 between 31 and 40 contemplates some impairment in reality testing or communication (e.g., speech 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). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Treatment records obtained in conjunction with the Veteran's claim reveal that at the time of a July 2002 VA outpatient visit, mental status examination revealed that the Veteran appeared to be his stated age, that he was cooperative, and that he had good eye contact. His speech had a normal volume and rate. His mood was euthymic and his affect was appropriate to thought with no lability. He was alert and oriented times four. Intellectual functioning was average and his thought process was clear, logical, and goal directed. He denied having any audio-visual hallucinations or homicidal/suicidal ideations. The Veteran also had no flight of ideas. At the time of the July 2006 VA examination, the Veteran reported having nightmares 4-5 times per week. He had thoughts of being worthless and did not want people around him. If someone came near him he would become angry. He did not think he was a good person. The Veteran stated he was irritable on a daily basis. He thought about shooting his stepdaughter's husband but denied any intent. He stated that the effects had impacted him so much that he had not been able to work for the past three years. The Veteran reported fighting a lot with his wife and stated he was having more conflicts with her. He noted having received three tickets in one year which caused his license to be suspended. The examiner indicated that the Veteran also had the psychiatric condition of depression. His current symptoms were sad daily mood, low energy, and lack of motivation and interest. He occasionally took his grandson to the park and/or went fishing. He reported that he liked to stay at home and avoid others. The Veteran stated that he could not focus and had trouble with his memory. He noted that the symptoms occurred constantly. The examiner reported that the effect the symptoms had upon total daily functioning was severe with crying spells, avoidance of others, and hyperventilation. The Veteran reported that he was currently married and described the relationship he had with his wife as good. This was his second marriage. He noted that the relationship with his two children and two stepchildren was also good. The Veteran indicated that due to his symptoms he was overall less active and stayed at home more. He noted that some days he stayed in bed and that he felt more depressed and irritable. He also reported having limited interaction outside his immediate family. Mental status examination revealed appropriate hygiene and appearance. Behavior was grossly inappropriate, with periods of excessive crying during the interview. Affect and mood were abnormal with depressed mood, which occurred near continuously and affected his ability to function independently. The Veteran noted staying in bed at times and not showering. He stated that his depression was chronic. Communication and speech were found to be within normal limits. He was able to concentrate at times but was so emotional that he had to stop talking. Panic attacks were absent. He did not trust people. There was no delusional history and there were no delusions or hallucinations observed at the time of the examination. Obsessional rituals were absent. Thought processes were appropriate and judgment was not impaired. Abstract thinking was normal and memory was found to be mildly impaired. There were passive thoughts of death but no plan or intent. Homicidal ideation was absent. The examiner rendered Axis I diagnoses of PTSD, chronic, mild; major depressive disorder, recurrent, chronic; and cannabis abuse, chronic, continuous. The depression was deemed to be related to the PTSD. The symptoms of each mental disorder could not be delineated from the other. The depression appeared to be the primarily disabling factor. The examiner assigned a GAF score of 50. The examiner stated that mentally, the Veteran occasionally had some interference in performing activities of daily living because of the severity of his depression. He noted that the best description of the Veteran's psychiatric impairment was that it caused occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks, although generally the person is functioning satisfactorily with routine behavior, self-care and normal conversation. The examiner indicated that the above statement was supported by the symptoms of depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, and chronic drug use. The Veteran had no difficulty understanding commands and appeared to pose no threat of persistent danger of injury to self or others. At the time of an August 2006 PTSD consultation, the Veteran reported that he was currently married and was close to his daughters, step children, and grandchildren. He enjoyed their company. He was noted to have been a courier until 2003, when his license was revoked. He was hopeful that he would be getting his license back. The Veteran reported that he slept 3-4 hours and that he had struck his wife in his sleep. He would awake drenched in sweat. His wife woke him with a long stick. Helicopters flying overhead triggered his symptoms. The Veteran reported doing perimeter checks at all hours and repeatedly looked out his window. He had a loaded weapon under his mattress for protection. Mental status examination revealed he was casually dressed and his grooming and hygiene were unremarkable. Eye contact was constant and he was cooperative. He was severely depressed with a pained affect and no lability. He was oriented to time, person, place, and situation. The Veteran admitted to recent and remote memory deficit. Intellect was average and thoughts were coherent, logical, and goal directed. Judgment was fair but insight was impaired. He was not suicidal but had attempted suicide years ago by playing Russian Roulette. The examiner rendered a diagnosis of chronic, severe PTSD and depression. He assigned a GAF score of 50 and noted that the Veteran had had a high GAF score of 53 in the past year. At a September 2006 outpatient visit, the Veteran reported sleeping only a few hours and being tense and irritable. He noted having trouble being around others and avoiding others. Helicopters startled him and triggered memories. Mental status examination revealed he was neatly groomed with normal activity and speech. He was tearful at times and mildly depressed and anxious with a decreased range and normal intensity of affect. He was oriented times three and his intellect was average. He was not psychotic and had no suicidal or homicidal ideations. Diagnoses of PTSD and marijuana abuse in partial remission were rendered. The examiner assigned a GAF score of 45. In a June 2007 telephone note, the Veteran called and stated he was tearful and upset as he was going through a divorce and feeling suicidal. He noted that he had choked his wife when waking from a nightmare. In a September 2007 telephone encounter, the Veteran reported that he was homeless and living with his son. In an October 2008 treatment note, it was indicated that the Veteran reported sleeping 6 to 7 hours per night. He still had nightmares. The Veteran stated that he was working and that he and his wife were helping their daughter, who had moved in with their three grandchildren. Mental status examination revealed the Veteran was neatly groomed and that he had normal activity and speech. His mood was euthymic and he was mildly irritable with a normal range and intensity of affect. He was oriented times three and had average intelligence. He was not psychotic and had no suicidal or homicidal ideations. The examiner rendered diagnoses of chronic PTSD, history of major depressive disorder, and marijuana abuse, and assigned a GAF score of 53. At the time of an August 2009 visit, the Veteran stated that he had run out of medication close to two months ago and was feeling worse. He reported smoking marijuana in order to go to sleep. He noted having increased nightmares and having hallucinations of someone screaming a few times per week. The Veteran continued to work but he isolated on the job. He had suicidal ideations a few times per week but kept going for his grandchildren. Mental status examination revealed he was neatly groomed with normal activity and speech. Mood was mildly depressed and irritable with a decreased range and normal intensity of affect. He was oriented times three and of average intelligence. He was not psychotic and had no suicidal/homicidal ideations. The examiner rendered diagnoses of chronic PTSD, recurrent major depressive disorder, and marijuana use, and assigned a GAF score of 51. At the time of a January 2010 VA outpatient visit, the Veteran reported that he was sleeping better. He noted having vivid dreams while on the medication. He reported auditory hallucinations of someone was calling his name and that he had some flashbacks. He noted being very irritable at times. He worked with his brother, who was trying to help him. Mental status examination revealed he was neatly groomed with normal activity and speech. Mood was mildly anxious and irritable with a decreased range and normal intensity for affect. The Veteran was oriented times three and had average intelligence. He was not psychotic or homicidal or suicidal. The examiner rendered diagnoses of chronic PTSD, improved major depressive disorder, and marijuana abuse, and assigned a GAF score of 53. At the time of an April 2010 VA outpatient visit, the Veteran reported that he was sleeping well. He again noted having vivid nightmares. He reported drinking two to three beers on the weekend and smoking marijuana three to four times per month. The Veteran felt depressed a few times during the day. Mental status examination revealed he was neatly groomed with normal activity and speech. His mood was euthymic and mildly anxious and irritable with a decreased range and normal intensity of affect. He was oriented times three and of average intelligence. The Veteran was not psychotic or suicidal or homicidal. The examiner assigned a GAF score of 53 and rendered diagnoses of chronic PTSD, improved major depressive disorder, and marijuana abuse. During a June 2010 visit, the Veteran reported having had three fights at work since his last appointment. He hit a young worker who had grabbed his shoulder and pulled a knife on a co-worker. The examiner indicated that anger management principles were discussed. Mental status examination revealed he was neatly groomed with normal activity and speech. His mood was euthymic and moderately irritable with a decreased range and normal intensity of affect. He was oriented times three and of average intelligence. He was not psychotic or suicidal or homicidal. The examiner assigned a GAF score of 51 and rendered diagnoses of chronic PTSD, improved major depressive disorder, and marijuana abuse. At the time of an October 2010 visit, the Veteran reported continuing to have problems at work and having difficulty getting along with his wife. He noted having suicidal ideations but stated that he wanted to keep living. Mental status examination revealed normal psychomotor activity and speech. Mood was mildly depressed with a mildly decreased range normal intensity of affect. He was oriented times three and his thoughts were logical, coherent, and goal directed. There were no delusions or hallucinations. The Veteran had fair judgment and insight and no current suicidal or homicidal ideations. The examiner rendered diagnoses of chronic PTSD, improved major depressive disorder, and marijuana abuse. He assigned a GAF score of 51. During a July 2011 visit, the Veteran reported worsening symptoms of depression and PTSD and stated that he only smoked marijuana to feel better. The Veteran was upset over his divorce and felt depressed over this. He had daily thoughts of suicide and had a gun at home which he thought he was going to use to kill himself. He said he did not use the gun as he strongly considered the negative effects it would have on his children. Hospitalization was addressed but the Veteran indicated that he had to work. Mental status examination revealed he was neatly groomed with normal activity level and speech. He was almost tearful and appeared to be depressed and distressed. His mood was moderately depressed with a normal range and intensity of affect. The affect was appropriate to immediate thought and it was not labile. He was oriented times three and was of average intellect. Thoughts were logical, coherent, and goal directed. He had no hallucinations or delusions. Judgment and insight were fair and there was no homicidal ideation. The Veteran reported having suicidal ideation several times daily. The examiner rendered diagnoses of chronic PTSD, major depressive disorder, and marijuana abuse, and assigned a GAF score of 50. At the time of an October 2011 visit, the Veteran was noted to have been off from work for three weeks following arm surgery. He noted being anxious around the house and stated he would go for a walk when he felt this way. He continued to have suicidal thoughts. Mental status examination revealed he was neatly groomed with normal activity level and speech. His mood was moderately depressed with a normal range and intensity of affect. The affect was appropriate to immediate thought and it was not labile. He was oriented times three and was of average intellect. Thoughts were logical, coherent, and goal directed. He had no hallucinations or delusions. Judgment and insight were fair and there was no homicidal ideation. The Veteran had suicidal thinking but no intent. The examiner rendered diagnoses of chronic PTSD, major depressive disorder, and marijuana abuse, and assigned a GAF score of 50. At the time of his May 15, 2012, VA examination, which served as the basis for the grant of the 100 percent disability evaluation by the AMC, the examiner indicated that the Veteran clearly met the criteria for PTSD as he had frequent nightmares, exaggerated startle response, was always on guard, had anger management problems, insomnia, social isolation, depression/suicidal ideation, and avoidance of crowds/cues. The examiner noted that the Veteran had symptoms of depressed mood, anxiety, panic attacks, chronic sleep impairment, a flattened affect, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including a worklike setting, an inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control, persistent delusions and hallucinations, and neglect of personal hygiene. The examiner rendered a diagnosis of PTSD and assigned a GAF score of 50, noting that the Veteran exhibited significant symptoms of PTSD and depression. It was indicated that his PTSD had contributed to two failed marriages, past job losses, extreme social isolation, and ongoing personal conflict at work. Evaluation in Excess of 70 Percent Prior to July 20, 2006 After a full review of the lay and medical evidence, the Board finds that the weight of the evidence does not demonstrate that prior to July 20, 2006, the criteria for a rating in excess of 70 percent for PTSD have been met. Prior to July 20, 2006, the record does not demonstrate gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; disorientation to time or place; or memory loss for names of close relatives, or own occupation. As noted above, at the time of a July 2002 VA outpatient visit, the Veteran was found to be cooperative, with his speech having a normal volume and rate. He was also noted to be alert and oriented times four and his thought process was clear, logical, and goal directed, with no audio-visual hallucinations or homicidal/suicidal ideations and no flight of ideas. As referenced above, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately, in Mauerhan, the Court upheld the Board's decision noting that the Board had considered all of the veteran's psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. Mauerhan v. Principi, at 444. Applying this analysis to the criteria for the 100 percent rating, it follows that the Veteran would be entitled to that rating if PTSD caused total occupational and social impairment, regardless of whether he had some, all, or none of the symptoms listed in the rating formula, and regardless of whether his symptoms were listed or not. In the present case, there was also no indication that the Veteran did not have contact or a good relationship with his family prior to July 2006. While the Veteran reported that he had not been working for the past three years at the time of the July 2006 VA examination, he attributed this to his having lost his license after having received three tickets in one year. In sum, the criteria for a 100 percent evaluation prior to July 20, 2006, were not met as the Veteran did not meet or approximate the criteria listed for a 100 percent disability evaluation nor was total occupational and social impairment demonstrated. Evaluation in Excess of 70 Percent for PTSD from July 20, 2006 The Board finds that the criteria for a 100 percent disability evaluation have been more closely approximated since July 20, 2006. The Board notes that the Veteran reported thoughts of worthlessness at the time of his July 2006 VA examination and thought about shooting his stepdaughter, demonstrating his being a danger to others. He was also unable to stay focused and had trouble with his memory. The examiner stated that the effect the symptoms had on daily functioning was severe with crying spells, avoidance of others, and hyperventilation, with mental status examination revealing his behavior to be grossly inappropriate with periods of excessive crying. It was further reported that affect and mood were abnormal and that his mood was continuously depressed, which affected his ability to function independently. A GAF score of 50 reflecting 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), was assigned. GAF scores of 50 and 45, again reflecting the serious symptoms noted above, were assigned at the time of August and September 2006 VA outpatient visits, with the Veteran indicating that he was only sleeping several hours per night and was tense and irritable and had trouble being around others at the time of the September 2006 visit. It is noted that although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See also 38 C.F.R. § 4.126(a) (an evaluation shall be based on all the evidence of record that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of examination). In June 2007, the Veteran was noted to be suicidal and he reported that he had choked his wife, actions which again demonstrate him being a danger to himself and others. In addition, the Veteran reported that he was homeless in September 2007, again a sign of being a danger to himself. In August 2009, the Veteran reported increased nightmares and having hallucinations of someone screaming his name along with suicidal ideations. He again reported hearing someone calling his name at the time of a January 2010 visit, and in June 2010 the Veteran reported he had been in three fights at work and had pulled a knife on a co-worker. In July 2011, the Veteran stated that he had daily thoughts of suicide and had a gun at home, which he thought he was going to use to kill himself, and he again reported having suicidal thoughts at the time of an October 2011 visit. These reports/events demonstrate the Veteran having what is akin to persistent hallucinations and being a persistent danger to himself and others, criteria necessary for a 100 percent disability evaluation. Moreover, GAF scores of 50 were assigned at the time of the June and October 2011 visits. Finally, while the Board notes that the AMC granted a 100 percent disability evaluation from May 15, 2012, based upon the results of the May 2012 VA examination, there is no indication that the symptoms reported at that time began on that specific date. The symptoms of depressed mood, anxiety, panic attacks, chronic sleep impairment, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including a worklike setting, an inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control, persistent delusions and hallucinations, have been shown in the aggregate since July 20, 2006. Given the foregoing, and resolving reasonable doubt in favor of the Veteran, the criteria for a 100 percent disability for PTSD have been approximated since July 20, 2006. Extraschedular Consideration The Board has considered whether an extraschedular evaluation would have been warranted for PTSD prior to July 20, 2006. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R.§ 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD for the time period prior to July 20, 2006, manifested symptoms which were either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with an acquired psychiatric disorder, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). (CONTINUED ON NEXT PAGE) ORDER An initial disability evaluation in excess of 70 percent for PTSD prior to July 20, 2006, is denied. An initial 100 percent disability evaluation for PTSD from July 20, 2006, is granted. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs