Citation Nr: 1306145 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 10-04 883 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for posttraumatic stress disorder (PTSD) prior to March 4, 2011. 2. Entitlement to an initial rating in excess of 50 percent for PTSD on or after March 4, 2011. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD G. E. Wilkerson, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1969 to December 1971. This case comes before the Board of Veteran's Appeals (Board) on appeal from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In that decision, the RO granted service connection for PTSD and assigned a 10 percent evaluation effective from September 14, 2007. During the pendency of the appeal, the RO issued another rating decision in December 2011 and increased the Veteran's disability evaluation for PTSD to 50 percent effective from March 4, 2011. However, applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). In July 2012, the Veteran presented testimony at a Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is of record. A review of the Veteran's Virtual VA electronic claims file reveals no additional records. FINDING OF FACT Throughout the appeal period, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, but he does not have total social and occupational impairment. CONCLUSIONS OF LAW 1. Resolving all doubt in favor of the Veteran, the criteria for an initial 70 percent disability evaluation, but no higher, for PTSD prior to March 4, 2011, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Codes 9411 (2012). 2. The criteria for an initial evaluation in excess of 70 percent for PTSD on or after March 4, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Codes 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it 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 the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). Upon receipt of an application for a service-connection claim, 38 U.S.C. § 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 claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing her or his entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Nevertheless, the Veteran in this case is challenging the initial evaluations assigned following the grant of service connection for his PTSD. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8-2003 (December 22, 2003). Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify has been satisfied with respect to the issues on appeal. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. The Veteran has not identified any outstanding records that are available and relevant to the claim being decided herein. Moreover, the record includes various written statements provided by the Veteran and his representative, as well as a transcript of the Veteran's July 2012 Board hearing. The Veteran was also afforded VA examinations in January 2009, January 2010, and March 2011. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Although the Veteran seems to suggest that these examinations may be insufficient, the Board finds that the VA examinations obtained in this case are adequate, as they are predicated on a review of the claims file and all pertinent evidence of record as well as on a mental status examination and fully address the rating criteria that are relevant to rating the disability in this case. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disability since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board concludes the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claim and did in fact participate. Washington v. Nicolson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. II. Law and Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 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 rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson, the Court noted an important distinction between an appeal involving a veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126. Here, as the RO has already assigned staged ratings for the Veteran's PTSD, the Board will consider the propriety of those ratings, as well as whether any further staged rating of the disability is warranted. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the RO granted service connection for PTSD in a January 2009 rating decision and assigned a 10 percent disability evaluation effective from September 14, 2007. In a December 2011 rating decision, the RO increased the evaluation to 50 percent effective from March 4, 2011. These ratings were assigned pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides that PTSD should be rated under the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. Under the general formula, a 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is assigned 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). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the 'psychological, social, and occupational functioning on a hypothetical continuum of mental health illness.' There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In this case, an August 2006 VA outpatient treatment record reflects that the Veteran reported increasing levels of anger and easy irritability. He noted that he became angry at work and just left. He indicated that he always had a short fuse, but now it was even shorter. He also stated that he had a disturbed sleep cycle and noted that he was isolating himself and more avoidant. He remained on guard and hypervigilant. On mental status examination, the Veteran was alert an oriented to all spheres, and his speech and thought process were normal. His mood was dysthymic with an anxious/restless affect. He did not have suicidal or homicidal ideation. During VA treatment in October 2006, it was noted that the Veteran was taking medication to treat his insomnia and anxiety. He reported having fair results when he took it on the weekend or as needed, although he had to deal with daytime sedation. Overall, he remained easily startled and irritated. He was working part-time repairing vacuums. The Veteran indicated that he might move back home to West Virginia to "get away." On mental status examination, his speech and thought processes were normal with relevant thought content, and his mood was dysthymic with an anxious/restless affect. He had no active suicidal or homicidal ideation. A December 2006 report notes that a physician spoke to the Veteran on the phone regarding a worsening of his PTSD and depressive symptoms due to being told that his job was being terminated, as well as his daughter moving back due to problems with finances. He felt closed in with a disturbed cycle, but he denied any suicidal or homicidal ideation or intent. A February 2007 VA outpatient treatment report reflects that the Veteran was being treated for PTSD due to his Vietnam experiences. He was started on medication for sleep and for daytime anxiety and other PTSD-related symptoms. He reported having hallucinatory experiences after only a few doses, which frightened him and he discontinued its use. The examiner discussed needing to consider other alternatives to help his sleep, which was very disrupted. He remained hypervigilant and easily irritable. On mental status examination, the Veteran was alert and oriented to all spheres, and his speech and thought process were normal with no delusions or perceptual disturbances. He was anxious throughout the interview with frequent monitoring of the window. His mood was dysthymic, and he had no active suicidal or homicidal ideation. An assessment of PTSD with associated dysthymia was indicated. Vet Center treatment records dated through February 2007 reflect that the Veteran sought individual counseling for his PTSD symptoms. These treatment records document the Veteran's struggles after dealing with the loss of his job. A May 2008 VA outpatient psychiatric consultation report indicates that the Veteran recently transferred to the Clarksburg, West Virginia, VA Medical Center from Florida. He was a retired sewing machine repairman who decided to move back to West Virginia where he grew up. He was living off of his savings from having sold his home in Florida. He reported that, since Vietnam, he experienced nightmares, had a "weird feeling" at times when in environments that reminded him of Vietnam, avoided images/television programs with war or combat in them, had increased irritability and hypervigilance, increased startle reflex, and avoided crowds. The Veteran also indicated that he was treated with multiple antidepressants for his depressive symptoms, but he could not tolerate them due to side effects. He was not interested in any other medications. There was no history of mania or psychosis. He smiled appropriately, joked, and enjoyed the interview. He did give a history of not caring if he lived or died, and he reported having thoughts at times while driving of going straight when the road curved. He had no intent, but had these thoughts related to frustration that he had arthritis in his hands and that his job in sewing machine repair was no longer valued. The Veteran presented approximately groomed and dressed, and he was oriented to person, place, time, and situation. There were no abnormal body movements observed. His speech was normal, and his mood was euthymic. He denied having hallucinations, obsessions, compulsions, or other signs of abnormal thought process and content. He also denied having current suicidal or homicidal ideation. The Veteran's attention was intact, and his memory was not impaired. The examiner indicated that insight and judgment were good. The examiner did note that the Veteran was isolated and needed more support. A diagnosis of PTSD and a GAF score of 72 was assigned. The examiner noted the Veteran's history of passive suicidal ideation with some rare active suicidal ideation without intent. He indicated that he discussed this with the Veteran in detail, and after careful consideration, felt that the Veteran was at low risk for harm to himself or others. He encouraged the Veteran to reach out to his neighbors and get involved in the community. It was noted that the Veteran did keep in contact with his daughter. The Veteran also underwent a behavioral health laboratory consultation. A depression screen revealed that the Veteran reported little interest or pleasure nearly every day, feeling down or hopeless more than half of the days, and difficulty sleeping nearly every day. He also endorsed feeling tired with low energy more than half the days, poor appetite or over-eating nearly every day, feelings of failure or guilt more than half of the days, trouble concentrating more than half of the days, and motor agitations nearly every day. He denied having any suicidal ideation. The result of the screen revealed severe depressive symptoms. The Veteran indicated that his depressive symptoms made it somewhat difficulty to do his work, take care of things at home, or get along with others. He was screened for suicidal ideation and found to not be at high risk. An anxiety screen reflects that he was moderately bothered by symptoms, such as disturbing memories, disturbing dreams, and feeling distant. He was bothered on occasion by re-experiencing events, physical symptoms, and feeling numb. He also reported that he experienced symptoms of being upset, loss of interest, easily startled, and feeling that life is shortened quite a bit. He denied having irritability, trouble sleeping, difficulty concentrating, avoiding activities, and trouble with recall. He was reportedly extremely anxious. The Veteran also denied alcohol and drug use, psychotic symptoms, or manic/hypomanic symptoms. On VA examination in January 2009, the Veteran reported that he was angered because he did not believe that he had been treated fairly. He expressed his belief that he had been exposed to Agent Orange in service, but that this had not been acknowledged. The examiner commented that the Veteran did not believe he was depressed, but instead viewed himself as "mad." The examiner also noted that the Veteran's symptoms appeared to suggest mild depression with irritability that was present chronically at least at mild levels. With respect to family relationships, the Veteran indicated that he was married once in 1978 and divorced 1982. He had one daughter. At the time of examination, he lived alone in a trailer on the top of a mountain. He reported that he had no friends. He had some people that he knew, but they did not live near him, and he did not involve himself with others very much. His mother and brother visited him yearly, but they lived in Texas. He also spoke to his mother weekly on the telephone. With respect to activities, he completed jigsaw puzzles by himself and worked outside in good weather. On mental status examination, the Veteran was appropriately dressed. Psychomotor activity was tense, and his speech was unremarkable. His attitude was cooperative with the examiner, and his affect was serious throughout. His mood was mildly to moderately irritable. The Veteran's attention and orientation was intact to person, time and place, and there was no impairment of thought process or communication. His thought content was unremarkable, and there were no delusions or hallucinations. His judgment was good and intelligence was average. With respect to insight, the examiner noted that the Veteran partially understood that he had a problem. In regards to sleep impairment, the Veteran indicated that he usually got no more than 3 to 4 hours of sleep during a 24 hour period. He reported that he was anxious when it was dark outside and stated that he could nap during the day when it was daylight. He did not have obsessive or ritualistic behavior. The Veteran endorsed panic attacks, but indicated that they happened only once every few years. Suicidal or homicidal thoughts were not present. His impulse control was fair, and though there were prior episodes of fights or violence, he had not been involved in any episodes the past 8 to 10 years. His memory was also normal. The examiner commented that the Veteran's PTSD symptoms, including intrusive, distressing recollections, diminished interest in activities, difficulty sleeping, irritability, and hypervigilance were mild, occurring a few time a week and lasting for periods of time-usually at least several minutes. With respect to work, the Veteran reported that he last worked in 2007 in sewing machine repair. He indicated that he worked for Singer for 30 years until it cut back its services in the 1990s. He tried to run his own business until 2004 and then worked at Sears, but the store closed. He had looked for work since, but he had been unable to find anything. The Veteran indicated that he believed this was largely due to his medical problems; however, the examiner noted that the Veteran did not contend that his unemployment was due to his mental disorder's effects. The examiner concluded by diagnosing the Veteran with PTSD and assigning a GAF score of 65. He noted that this GAF score represented mild symptoms of PTSD with mild social impairment and mild occupational impairment. The examiner indicated that the Veteran was quite socially isolated with few recreational or leisure pursuits and that it appeared that these functional problems were largely due to his PTSD symptoms. The examiner determined that the Veteran's PTSD signs and symptoms were transient or mild and led to decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner noted that, while the Veteran's PTSD did not play a role in his unemployment, it would likely decrease his ability to perform occupationally at times. An October 2009 VA outpatient psychiatry consult reflects that the Veteran reported increased depression, anger, and irritability over the past year. He indicated that he was very socially isolated and that he did not go anywhere unless he absolutely had to. He stated that he did not associate or communicate with his neighbors. He reported decreased sleep for a number of years and noted that he only slept a few hours per night. He indicated that he woke up in a sweat 2 to 3 times per week. He also experienced decreased energy and interest and had difficulty planning for the future. The Veteran also endorsed exaggerated startle response and hypervigilance, and he indicated that he had problems with anger. He did not take any psychiatric medication due to side effects. With respect to family, he reported that he still kept in good contact with his daughter, who lived in Florida. He no longer worked in sewing machine repair, as the position was no longer in demand. On mental status examination, the Veteran presented as casually dressed. He was cooperative and engaging, but irritable. His thought processes were logical and coherent without evidence of psychosis, and he denied any current suicidal or homicidal ideation. His mood was angry and irritable, and his affect was angry. The Veteran's cognitive functioning was intact, and his insight and judgment were fair. A diagnosis of PTSD and a GAF score of 50 were assigned. A December 2009 VA outpatient treatment record reflects that the Veteran continued to report symptoms of decreased sleep, decreased energy, decreased interest, irritability, and hypervigilance. He presented as casually dressed, slender, and bearded. He was irritable and somewhat withdrawn, but he was cooperative. The Veteran's thought processes were logical and coherent without evidence of psychosis. He did not have any current suicidal or homicidal ideation, but was vague about how he would cope in the future. His mood was angry and irritable, and his affect was angry. The Veteran's cognitive functioning appeared intact, and his insight and judgment were fair. Diagnoses of PTSD and mood disorder, as well as a GAF score of 50, were assigned. On VA examination in January 2010, the Veteran reported that he attended a Vet Center group about once a week. His relationships with his peers were fine, and he arrived early to socialize when he was able. He was still not taking any psychiatric medication. With respect to family relationships, he indicated that he divorced a long time ago and kept in touch with his daughter, who lived in Florida and called him two to three times per week. He reported that he moved to West Virginia because he was born there, but later said that he left Florida in the wake of conflicts with his noisy neighbors. In regards to other social relationships, the Veteran indicated that he did not socialize with people he knew from the past in Sutton. He noted that he wished there were more opportunities to socialize informally. Leisure activities included putting together jigsaw puzzles. The Veteran reported a history of violence, in that he waved an unloaded gun at noisy neighbors around 2000 and was frequently irritable while working for Singer. The examiner's summary of the Veteran's current psychosocial functional status noted that he had reached a stage in life where his health was failing (shortness of breath with mild exertion, fatigue, arthritis pain, limited strength and dexterity in hands). Based on his report, he was chronically sleep-deprived. He was unemployed and felt useless. He was pessimistic about his chances of finding a job because of his history of heart surgery and because he could not perform mechanical work as well as he could in the past because of arthritis. He was in severe financial distress with his income coming only from VA benefits. The examiner indicated that the Veteran felt betrayed by VA and was angry with the compensation system for not adequately compensating his PTSD and viewed this as the only solution for his financial situation. He denied feeling helpless and hopeless, but said he was "getting there." He did speak of a plan to commit suicide-by-police, probably in a hostage situation using a regional office employee and unloaded weapon. The examiner indicated that they discussed other ways of obtaining financial relief and reported that, by the end of the session, his intent to commit suicide seemed to have lessened and he had courses of action to take to improve his living situation and quality of life. He planned to continue going to the Vet Center group. On mental status examination, the Veteran was casually dressed, thin, with poor dentition, long fingernails, and a long beard. Psychomotor activity was tense, and his speech was unremarkable. His attitude toward the examiner was evasive and irritable, although he relaxed and smiled as the examination progressed. His affect was constricted, his mood was anxious and dysphoric, and his attention was intact. The Veteran was oriented to time, place, and person, and his thought process was unremarkable. With respect to thought content, the examiner noted that the Veteran was very preoccupied with the VA compensation system and spoke of involving the person who signed his next decision letter in a suicide-by-police altercation. He had no delusions, and his judgment and insight were good. He had sleep impairment and only slept three to four hours per day. He complained of being afraid of the dark because that was when most of the attacks happened. He denied flashbacks and hallucinations at night. The examiner noted that the Veteran had inappropriate behavior in that he had excessive anger at the VA compensation system and directed all of his anger about his health condition and financial distress at the compensation system. He did not have obsessive or ritualistic behavior or panic attacks. With respect to homicidal thoughts, the Veteran indicated that he planned to have a "meeting with Jesus" with whomever signed off on the decision letter from this report. There was also the presence of suicidal thoughts in that the Veteran stated that he fully intended to create a situation where the police "did not have a choice" and would have to assume it was his life or someone else's life. The victim of the assault would be whomever signed off on the report. The examiner commented that this intent seemed to have weakened by the end of the session after spending some time exploring alternative solutions to his problems. The Veteran did not have any current episodes of violence, although he did in the past, and impulse control was noted to be good. The Veteran was able to maintain minimum personal hygiene, and there was no problem with activities of daily living. Memory was noted to be normal. The examiner noted that the Veteran would not or could not talk about his problems that he attributed to having served in Vietnam. He was initially very tense and irritable with brusque interactions. As the interview progressed, he relaxed and talked about his feelings of having to jump through hoops with VA, indirect suicidal ideation, feelings of worthlessness, difficulty coping, severe financial distress, and failing health. He denied having panic attacks, but did avoid going into places when he felt something was not right. He was lonely and opportunities for interaction were slim because of his geographic isolation. The examiner noted that the Veteran was retired and left employment in 2007 because Sears consolidated its repair facility and he did not want to move to a new location with uncertain job security. He complained of difficulty being hired because of his heart surgery and difficulty doing mechanic work because of arthritis in his hand as well as his relative geographic isolation in West Virginia. The examiner diagnosed PTSD, mild, and assigned a GAF score of 65. The examiner noted that the GAF was an estimate of the Veteran's functioning considering his PTSD symptoms, the primary of which were signs of persistently increased arousal-sleep disturbance, hypervigilance, and irritability. The Veteran's sleep disturbance could be traced to active duty combat in which nighttime attacks were common. The examiner noted that the lack of restorative sleep undoubtedly contributed to the Veteran's frustration, anger, and depression. As for the extent to which disorders other than PTSD were independently responsible for impairment in psychosocial adjustment and life quality, the examiner commented that the Veteran's depression was secondary to ongoing stressors of severe financial distress, unemployment, and lack of available social or support systems. His prognosis was guarded given the chronicity and ongoing stressors. In a February 2010 statement, the Veteran's representative wrote indicating that he received a call from a patient representative at the VAMC in Clarksburg in January 2010 who informed him that the Veteran had planned to go to a certain location with an unloaded pistol until he was shot and killed by authorities. He expressed that he considered this an active plan of self-harm. On VA examination in March 2011, the Veteran reported that he continued to attend a weekly Vet Center group. The Veteran's subjective complaints included an inability to relax and let his guard down. He noted that he trusted some of his PTSD group members, but did not socialize with them outside of the group. The only other social contact he had was phone calls with his daughter twice a week and mother once a week. Activities and leisure pursuits included television and jigsaw puzzles, although he did "wander around" his property when the weather was nice. On mental status examination, the Veteran's appearance was good with good eye contact, and his speech was relevant and coherent. His mood was constantly aggravated and agitated with high anxiety. He acknowledged homicidal thoughts and ideas, but there was no particular intention or plans. He denied suicidal thoughts, ideation, intentions, or plans. The Veteran's thought process was psychotic with delusions and hallucinations. He held beliefs of a delusional quality based upon his distrust, but did not elaborate. With respect to hallucinations, he noted that he heard his name being called from a distance. Intellectual and sensorial functioning was grossly within normal limits. His judgment was intact, although with respect to insight, the examiner commented that the Veteran was in need of psychotherapy, but denied medication. The examiner noted that the Veteran was able to maintain minimal personal hygiene and do other basic activities of daily living. With regard to obsessive or ritualistic behavior, he kept the widows clear for a view around his home and also had dusk-to-dawn lights. He denied having panic attacks. There were no impulse control problems. With respect to sleep, he rested three to four hours per day. The examiner commented that the last examiner indicated that, while the Veteran's PTSD was mild, he also alerted authorities of homicidal potential, which normally would follow a more serious condition. Therefore, he found the examiner's report and actions to be inconsistent. A diagnosis of PTSD and GAF score of 50 was assigned, and the examiner commented that the Veteran had psychotic features with delusions and hallucinations as well as homicidal thoughts. The examiner noted that the Veteran's psychosocial functioning status and quality-of-life, since his last examination had remained marginal and serious. He stated that the Veteran's PTSD symptoms isolated him and kept him hyper-aroused. With respect to effects of PTSD on occupational and social functioning, the examiner determined that there was an occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to signs and symptoms, but generally satisfactory functioning. The examiner noted that PTSD would not be a factor in either physical or sedentary employment, but rather the serious nature of his disorder, including homicidal thoughts and ideas well as delusional and hallucinatory thought disorder would impede his ability to stay employed. During the Veteran's July 2012 Board hearing, he reported that he sought treatment for the past three years at the Vet Center. He indicated that his treatment provider never indicated that his condition had worsened, but stayed at the same level of severity. He reported that he did not find that the 2010 VA examiner's conclusions matched the findings made during the examination. He endorsed symptoms of panic attacks, anxiety, night sweats, isolation from others, lack of sleep, and little interest in activities. He reported that he socialized with a neighbor on occasion. With respect to work, he noted that he retired because of his hands and the fact that his profession was no longer hiring. He reported little problems at work when he was employed as long as he was left alone. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a 70 percent disability evaluation throughout the appeal period beginning on September 14, 2007. The aforementioned evidence reflects that the Veteran's PTSD has been manifested by difficulty sleeping, mood swings, irritability, anger, anxiety, depression, isolative behavior, and paranoia. He has also been documented as having some hallucinations. Significantly, the Veteran has intermittently reported suicidal ideation throughout the appeal period, and on several occasions, he described his specific plans to commit suicide by taking hostages and putting himself in a situation where authorities would kill him. In addition, a May 2008 VA outpatient psychiatric consultation report noted that the Veteran had severe depressive symptoms, and the March 2011 VA examiner commented that the Veteran's psychosocial functioning status and quality of life was marginal and serious. While the Veteran has not demonstrated all of the symptoms listed in the rating formula as indicative of a 70 percent rating, the Board finds that his overall symptomatology picture, particularly, isolative behavior, symptoms of depression and anxiety, and suicidal ideation, more closely approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood. Thus, with resolution of all reasonable doubt in the Veteran's favor, the Board finds that his PTSD has more nearly approximates the criteria for an initial 70 percent rating, but no higher, since September 14, 2007. See 38 C.F.R. §§ 4.3 4.7. However, at no point has the Veteran's PTSD symptomatology met the criteria for the next higher 100 percent rating. As noted above, a 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name38 C.F.R. § 4.130. The evidence does not show that the Veteran has had impairment in thought processes or communication or disorientation to time or place. In fact, numerous medical records noted that his thought process and speech were normal and that he was oriented to person, time, and place. He also denied having any delusions on all occasions, except for the March 2011 VA examination, which suggests that such symptomatology is not persistent. Similarly, while the Veteran has expressed suicidal ideation, the evidence does not show that there was a persistent danger. Rather, by the end of most evaluations, the level of risk seemed to be lowered after talking to a therapist. Moreover, he often denied having suicidal and homicidal ideation, such as noted in the August 2006, October 2006, December 2006, and February 2007 VA treatment records, the January 2009 VA examination report, and the October 2009 VA medical record. Thus, his thoughts of hurting himself or others do not appear to be persistent, as they instead seem to be intermittent and fluctuate in level of risk. The Board points out that in determining that the criteria for an initial rating in excess of 70 percent for the Veteran's service-connected PTSD are not met, the Board has considered applicable rating criteria not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for the psychiatric disability in question. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Moreover, while the Veteran is socially isolated and lives far away from most of his family, he is still in weekly contact with his daughter and his mother. The Veteran also discussed socializing with his neighbor and other members of his Vet Center therapy group. Thus, it appears that the Veteran is able to maintain social and family relationships. In addition, the Board notes that the Veteran's PTSD has not been shown to cause total occupational impairment. Although the Veteran is unemployed, the evidence does not show, and the Veteran does not contend, that such unemployment is due to his PTSD. Rather, the Veteran has indicated that he retired, that his skills are no longer in demand, and that his other medical problems, such as arthritis, caused him employability issues. In fact, the Veteran testified in July 2012 that his PTSD did not cause him too many problems at work. The Board notes that the March 2011 VA examiner indicated that PTSD could impede the Veteran's work, but he also stated that PTSD would not be a factor in either physical or sedentary employment. The Board further notes that none of the GAF scores assigned since the effective date of the grant of service connection, ranging from 50 to 72, alone, provide a basis for assigning a rating in excess of 50 percent for PTSD. According to DSM-IV, a GAF score ranging from 41 to 50 reflects severe 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), while a GAF score ranging from 51 to 60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). 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 In this case, the GAF scores of 65 and above found on VA examination and in outpatient records clearly reflect even less impairment than that contemplated in the current 70 percent rating; hence, these scores provides no basis for a higher, initial rating. While the GAF score of 50 assigned by the March 2011 VA examiner and in outpatient records might suggest some impairment greater than that contemplated the initial 70 percent rating assigned, it is but one factor for consideration in assigning a rating in this case. When all of the evidence and findings contained therein are considered, including the degree of functioning as evidenced by these reported scales, the overall evidence does not establish a level of impairment that more nearly approximates a 100 percent rating. As noted above, the Veteran has maintained some relationships, and his unemployment is due to factors other than PTSD. Thus, it cannot be said that he has total social and occupational impairment. Accordingly, the Board finds that an initial 70 percent, but no higher, rating for PTSD is warranted for the entire appeal period. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's service-connected PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). 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. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation 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 the extraschedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, which primarily consists of sleep impairment, isolation, suicidal ideation, irritability, depression, and anxiety. Indeed, the 70 percent evaluation contemplates the overall effect of all of his symptomatology on his occupational and social functioning. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected PTSD under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Subject to the provisions governing the award of monetary benefits, an initial 70 percent disability evaluation is granted for PTSD for the entire appeal period. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs