Citation Nr: 1304765 Decision Date: 02/08/13 Archive Date: 02/19/13 DOCKET NO. 05-28 820A ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently rated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his daughter ATTORNEY FOR THE BOARD Tiffany Berry, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1967 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction over the appeal currently resides with the RO in Houston, Texas. The Veteran and his daughter testified at a May 2011 hearing sitting at the RO before the undersigned Acting Veterans Law Judge. A transcript of that hearing is associated with the claims file. In April 2012, the Board remanded this claim for additional development and adjudication. All requested actions have been completed and the claim is once again before the Board. FINDING OF FACT The most competent and credible evidence of record shows that the Veteran's PTSD causes no more than occupational and social impairment with occasional decrease in work efficiency at all times during the pendency of the appeal. CONCLUSION OF LAW The criteria are not met for a disability rating higher than 30 percent for PTSD at any time during the pendency of the appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.7, 4.130, Diagnostic Code (DC) 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held 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) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, May 2004 and February 2007 letters advised the Veteran of the evidence and information necessary to substantiate his claim for an increased rating for his PTSD, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the February 2007 letter advised him of the information and evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. While the February 2007 letter was issued after the initial October 2004 rating decision, the United States Court of Appeals for the Federal Circuit has held that VA could cure such a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication of the Veteran's claim. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the February 2007 letter was issued, the Veteran's claim was readjudicated in the January 2008 supplemental statement of the case. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Furthermore, even if VA did not provide adequate notice in the above letters, the Board finds that this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claim after reading the above VCAA letters as well as the rating decisions, statements of the case, supplemental statements of the case, and Board remand. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA treatment records through April 2012, Vet Center records, and Social Security Administration (SSA) records have been obtained and associated with the Veteran's paper and virtual files. The Board notes, however, that the Veteran is not in receipt of SSA disability benefits on account of a psychiatric disorder. Therefore, these records are not relevant to the Veteran's claim for an increased rating. The Veteran has not identified any additional outstanding records that have not been requested or obtained. The Veteran was also afforded VA examinations in August 2004, May 2007, November 2009, and June 2012 in conjunction with the claim on appeal. Neither the Veteran nor his representative has alleged that the examinations are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected PTSD as they include interviews with the Veteran, a review of the record, and full mental examinations, addressing the relevant rating criteria. Additionally, neither the Veteran nor his representative has alleged that his PTSD has worsened in severity since the June 2012 VA examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). Therefore, the Board finds that the examinations of record are adequate to adjudicate the Veteran's increased rating claim and no further examinations are necessary. In April 2012, the Board remanded the case for additional development. As discussed in the preceding paragraphs, Vet Center records and SSA records were obtained, and the Veteran was afforded a VA examination in June 2012 to assess the severity of the Veteran's PTSD, in accordance with the April 2012 remand directives. Therefore, the Board finds that the AOJ has substantially complied with the April 2012 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Finally, the Veteran provided relevant testimony during the hearing before the undersigned in May 2011. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the undersigned Acting Veterans Law Judge identified the issue on appeal and solicited the Veteran to identify evidence relevant to the claim. The Veteran described the impact of the disability on his activities of daily living. At the Board hearing, his testimony revealed a possible worsening of the disability since the last VA examination and the Board sought additional development to rectify the deficiency in its April 2012 remand directive. The Board also obtained updated treatment records and SSA records. As such, the Board finds that the hearing discussion did not reveal any evidence that might be available, but was not associated with the claims file, other than medical evidence that was to be procured. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. In adjudicating the claim below, the Board has reviewed all of the evidence in the Veteran's record including those found in virtual VA. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims files shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. By way of history, an October 1970 rating decision granted service connection for PTSD and assigned an initial, noncompensable, disability rating. In a subsequent February 2003 rating decision, the Veteran's disability rating was increased to 30 percent. He again filed for an increased rating in April 2004, which was denied in the October 2004 decision on appeal. The Veteran timely appealed such adverse decision. He alleges that his PTSD warrants a higher rating. The Veteran's PTSD is currently evaluated under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411, which pertains to PTSD. Under such regulations, ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates 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. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). Under the General Rating Formula, a 30 percent disability rating is appropriate when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. The criteria for a 50 percent disability rating requires 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; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: 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. The criteria for a 100 percent rating are: 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. In evaluating the evidence, the Board also has considered various Global Assessment of Functioning (GAF) scores that clinicians have assigned. A GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (March 31, 1995). A GAF of 41-50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See DSM-IV; see 38 C.F.R. § 4.130. A GAF score of 51-60 indicates "[m]oderate 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)." Id. A GAF score of 61-70 indicates "[s]ome 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." Id. In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998). In August 2004, in connection with his claim for an increased rating, the Veteran had a VA compensation examination to assess the severity of his PTSD. The report notes that the Veteran was not receiving any treatment. He reported that he avoids crows, has intrusive thoughts of combat, and irritability. As for employment, the Veteran stated he quit working in October 2003 because he got into disagreement with his supervisors, and his arms and legs hurt. He has not worked since that time. The examiner also noted the Veteran has been married for 32 years, and has a few friends with whom he visits and sometimes has meals. He watches television, helps care for his grandchildren, and fishes. Upon objective mental examination, the Veteran denied any suicidal and homicidal ideations, hallucinations, or delusions, but he did report that he feels as though he is being watched and checks the house at night. The examiner noted the Veteran's eye contact was normal, he can maintain personal hygiene, and he is oriented to person, place, and time. The Veteran did report difficulties remembering many events from Vietnam, but his concentration was judged intact. The Veteran also remembered three objects on immediate recall, but could only remember one object after 10 minutes. The Veteran's speech and impulse control were normal. He did indicate that he suffers from decreased energy and motivation, however, denied all other symptoms of depression. The Veteran also reported sleep impairment by awakening to listen for noises and checking the house for safety. The examiner also noted the Veteran's symptoms of avoidance, inability to show affection and feelings of detachment and estrangement, hypervigilance, hyperarousal, increased irritability, and sleep disturbances. The examiner stated that these symptoms cause significant distress and impairment in social functioning. He also stated that the Veteran's symptoms are of moderate severity and occur daily. A GAF score of 60 was assigned, which is indicative of moderate symptoms. In May 2007, the Veteran again underwent evaluation for his PTSD. The symptoms the Veteran described included distressing dreams and he awakes from them depressed, anxious, and in a cold sweat. Upon objective mental examination, the examiner stated the Veteran is a reliable historian, who is oriented to time, place, person, and the purpose of the interview. His behavior was described as appropriate, affect adequate, and mood depressed. The Veteran stated he works on his impulse control, but does have irritability problems which affect his mood because it is discouraging. The Veteran's speech was noted as clear, coherent, and spontaneous, with good concentration. He denied suffering from panic attacks, hallucinations, delusions, obsessive rituals, and suicidal and homicidal ideations. The examiner did conclude that the Veteran has cognitive, social, effective, and traumatic symptoms attributed to his PTSD, but did not provide any further comment. The examiner also indicated the Veteran is able to establish and maintain effective work and social relationships. Ultimately, the examiner stated that he doubts psychiatric treatment is going to make much of difference in his condition and does not expect much further improvement. A GAF score of 55 was assigned, which is indicative of moderate symptoms. In November 2009, the Veteran was again provided a VA examination to reassess the severity of his PTSD. This examination noted the Veteran's ongoing treatment for his psychiatric disorder, including medications. The Veteran reported that his anger and irritability have improved with psychotropic medication, and his sleep has mildly improved. He also fishes on and off in the summer, visits with his family on occasion, is able to shop by himself or with his wife, and can eat at a restaurant once or twice a week, but continues to have strong discomfort in public. The examiner noted the Veteran's symptoms are of moderate severity and chronic in nature. The Veteran also complained of memory problems and gaps in his memory, hypervigilance, exaggerated startle response, and difficulty concentrating. Upon objective mental examination, the Veteran was described as clean, neatly groomed, and casually dressed. His speech was unremarkable, attitude cooperative, normal affect, with a sad and neutral mood. His attention was intact, and he was properly oriented to time, place, and person. The Veteran was noted to have mild circumstantial thought, and understands outcomes of behavior. The examiner noted the Veteran's sleep impairment, and obsessive/ritualistic behaviors in checking the doors three times to make sure they are locked. The Veteran also reported panic attacks occurring 1 to 2 times a week. Homicidal ideations were denied, but the examiner noted the Veteran has suicidal thoughts, with no intent or planning. The Veteran's remote, recent, and immediate memory was mildly impaired. The examiner noted the Veteran's PTSD is indicative of reduced reliability and productivity. A GAF score of 58 was assigned, which is indicative of moderate symptoms. Most recently, the Veteran was evaluated in June 2012, in compliance with the Board's April 2012 remand directives. During the examination, the Veteran stated he has been married for 42 years and his marriage was improving. He stated he retired 9 years ago. The examiner noted the Veteran's symptoms include recurrent and distressing recollections, intense psychological distress, proactive avoidance techniques, marked diminished interest or participation in activities, difficulty falling or staying asleep, hypervigilance, and irritability. Additionally, the Veteran reports depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, inability to establish and maintain effective relationships, disturbances in motivation and mood, and difficulty adapting to stressful circumstances. The Veteran denied any suicidal thoughts or ideations. The examiner noted the Veteran is still receiving treatment for his PTSD and has been more compliant in taking his medications. Ultimately, the June 2012 examiner determined the Veteran's PTSD causes occupational and social impairment with occasional decrease in work efficiency. A GAF score of 62 was assigned, which is indicative of mild symptoms. Also on file for consideration are VA treatment records, dated through April 2012 at VA medical centers, and he has received mental health treatment at the Vet Center from May 2008 to April 2010. These treatment records show the Veteran's continuous participation in psychiatric treatment for his PTSD throughout the entire appeals period. These records also are repetitive of the symptoms described by the numerous VA examiners during their evaluations of the Veteran from August 2004 to June 2012. Tellingly, nothing in these treatment records shows the Veteran's adverse psychiatric symptomatology because of his PTSD worse than what was reported at the above VA examinations. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions) Finally, the Veteran submitted five lay statements from his children attesting the severity of his PTSD. The lay statements provided note the Veteran's irritability, anger, and depressed mood. As indicated previously, a 50 percent disability rating requires 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; difficulty in establishing and maintaining effective work and social relationships. Based on the evidence of record, the Board finds that the Veteran's PTSD does not result in occupational and social impairment with reduced reliability and productivity. First, the Board notes that the only report of a suicidal ideation was in the November 2009 VA examination report, but the examiner specifically noted they were episodic thoughts, with no intent or plan. The Veteran specifically denied suicidal thoughts or ideations during the August 2004, May 2007, and June 2012 VA examinations. The November 2009 VA examiner also noted the Veteran suffers from panic attacks, and determined the Veteran's PTSD symptoms are indicative of reduced reliability and productivity. However, as discussed below, the Board finds that, despite the findings in the November 2009 VA examination, the competent evidence in the aggregate does not show the Veteran's PTSD symptomatology more nearly approximate a 50 percent rating. In this regard, there is no evidence that the Veteran has obsessional rituals which interfere with routine activities. The August 2004, May 2007, November 2011, and June 2012 VA examiners all found that the Veteran's thought processes were intact. Also, the Veteran has consistently denied hallucinations, delusions, suicidal and homicidal thoughts and ideations. The November 2009 VA examiner found that the Veteran did have obsessional rituals in checking the locks on the doors and windows three times at night. However, none of the other VA examiner determined this behavior was indicative of obsessional rituals. Additionally, his speech has never been described as illogical, obscure, or irrelevant. In fact, during the all four VA examinations it was described as logical and coherent. There is also no evidence of near-continuous panic or depression affecting the Veteran's ability to function independently, appropriately, and effectively. In this regard, the Veteran has reported feelings of depression and panic attacks occurring more one to two times a week. Specifically, he reported during the November 2011 examination that he had panic attacks three to four times a week. However, the Board finds that panic attacks occurring one to two times a week does not rise to the level of near-continuous and, moreover, the evidence does not suggest these panic attacks have affected his ability to function independently, appropriately, and effectively. Additionally, there is no evidence that the Veteran suffers from impaired impulse control during the current appeal period. The Veteran has been described as irritable, and the lay statements provided by his children indicate he does yell and get loud at times. Even so, there was no indication that the Veteran had a problem with authority, and there was no history of violence/assaultiveness was noted. Therefore, while he is irritable, the Veteran's impulse control has predominantly been noted to be intact. Moreover, the Veteran has never been noted to have spatial disorientation. In this regard, all VA examinations reveal that the Veteran was consistently alert and oriented. The Board further finds that the evidence fails to demonstrate that the Veteran neglects his personal appearance and hygiene. Regarding the Veteran's ability to establish and maintain effective relationships, the Veteran has been married for 42 years as of the June 2012 VA examination and he stated his marriage was improving. He reported he goes out to eat, fishes, and visits with family. He stated he even goes shopping by himself or with his wife. Therefore, the Board finds that the Veteran is able to establish and maintain effective relationships, even if he has some difficulty. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating criteria, to include intrusive recollections and dreams, hypervigilance, avoidance, markedly diminished interest or participation in significant activities, exaggerated startle response, difficulty sleeping, and difficulty concentrating. See Mauerhan, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 30 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with reduced reliability and productivity. In reaching this decision, the Board has also considered the Veteran's GAF scores. The Board notes the Veteran's GAF scores range between 55 and 62 for the entire appeals period, representative of no more than moderate symptoms. Likewise, the Board finds that the evidence of record, as discussed in detail above, supports the conclusion that the Veteran's PTSD results in moderate symptomatology, rather than severe. In making such determination, the Board has considered the type and severity of symptomatology. In the absence of more severe symptoms occurring more frequently, the Board finds that his currently assigned 30 percent rating more nearly approximates the overall severity of the PTSD despite the problems with mild circumstantial thought, sleep impairment, obsessive/ritualistic behaviors, panic attacks occurring 1 to 2 times a week, and suicidal thoughts reported by the November 2009 VA examiner. 38 C.F.R. §§ 4.3, 4.7; Also see Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases). In reaching this decision, the Board observes that, during the numerous mental status examinations, the Veteran was noted to suffer from moderate severity PTSD symptoms. During the November 2011 VA examination, the examiner determined the Veteran's PTSD symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; however, he specifically found that such resulted in no more than occupational and social impairment with reduced reliability and productive rather than deficiencies in most areas or in total occupation and social impairment. This was the only examination to determine the Veteran's PTSD symptoms resulted in reduced reliability and productivity. Instead, the other VA examiners all noted the moderate severity of the Veteran's reported symptoms only cause occasional decrease in work efficiency, which have remained fairly constant through the entire appeals period. Therefore, the Board finds that the most competent and credible evidence of record, as discussed in detail above, supports the conclusion that the Veteran's PTSD results in moderate symptomatology, rather than severe. Based on his ability to maintain his marriage, familial and personal relationships as well as go out in public to the store and restaurants, the Board finds that his PTSD results in occupational and social impairment with occasional decrease in work efficiency. Therefore, the criteria for a 50 percent rating are not met. Moreover, the Board finds that the criteria for a 70 percent rating under the General Rating Formula are not met. In this regard, the evidence does not show that the Veteran has 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. The evidence of record also does not indicate the Veteran's PTSD meets the criteria for a 100 percent rating by causing, among other things, reduced reliability with 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. Accordingly, the Board finds that the medical and lay evidence does not support a rating in excess of 30 percent for the Veteran's PTSD at any point during this appeal period. 38 C.F.R. § 4.130, DC 9411. The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. 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. Second, 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 "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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. Id. With respect to the first prong of Thun, the Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. The Board finds that the symptomatology associated with the Veteran's PTSD is fully addressed by the rating criteria under which this disability is rated. There are no additional symptoms for that are not addressed by the rating schedule. In this regard, the Board has considered the totality of the Veteran's PTSD symptomatology in determining the impact that it has on his occupational and social functioning. See Mauerhan, supra. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his PTSD. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." Specifically, there simply is no objective evidence that his PTSD, acting alone, has resulted in frequent periods of hospitalization or in marked interference with employment. See Bagwell v. Brown, 9 Vet. App. 337 (1996). Therefore, the Board finds that the evidence does not demonstrate an exceptional or unusual clinical picture beyond that contemplated by the rating criteria. In short, there is nothing in the record to indicate that this service-connected disability causes impairment with employment over and above that which is contemplated in the assigned schedular ratings. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted, In reaching the above conclusions, the Board has not overlooked the various lay statements found in the record. In this regard, the Veteran is credible to report on what he sees and feels and others including his family members are credible to report on what they can see. See Davidson, supra. However, the Board finds more competent and credible the medical opinions as to the severity of his disability provided by the experts at the Veteran's VA examinations than these lay assertions. See Black v. Brown, 10 Vet. App. 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the 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 the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators. . ."). In adjudicating the current appeal for an increased rating, the Board has not overlooked the Court's holding in Rice v. Shinseki, 22 Vet. App. 447 (2009) (per curiam) (holding that claims for higher evaluations also include a claim for a total rating based on individual unemployability (TDIU) when the appellant claims he is unable to work due to a service connected disability). However, the Board finds that Rice is not applicable to the current appeal because the Veteran has never claimed that the above disability acting alone prevents him from obtaining and/or maintaining employment. Therefore, the Board finds that the current decision need not consider whether the Veteran meets the criteria for a TDIU. In adjudicating the current appeal for an increased rating, the Board has also considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 2002); see also, e.g., Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the claim for an increased rating for PTSD must be denied. ORDER Entitlement to a disability rating higher than 30 percent for PTSD is denied. ____________________________________________ NEIL T. WERNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs