Citation Nr: 1307645 Decision Date: 03/07/13 Archive Date: 03/11/13 DOCKET NO. 06-08 076 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office and Insurance Center in Philadelphia, Pennsylvania THE ISSUE Entitlement to initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to February 23, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. J. Nardone, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1985 to December 1985, from October 1987 to March 1988, from July 1988 to July 1991, and from August 2002 to May 2003. He had additional service with the Pennsylvania Army National Guard. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) and Insurance Center in Philadelphia, Pennsylvania that assigned an initial rating of 30 percent for PTSD, effective from May 9, 2003. In a July 2007 rating decision, the originating agency increased the evaluation in effect for PTSD to 50 percent, effective from July 12, 2006. By rating decision dated in November 2010, the RO increased the evaluation in effect for PTSD to 70 percent, effective from February 23, 2010. In March 2009 the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that proceeding is of record. The Board remanded this issue for further development in May 2009. The case was returned to the Board, and in a decision dated in September 2011, the Board granted an initial rating of 50 percent, but not more, prior to July 12, 2006, and denied entitlement to a rating higher than 50 percent from July 12, 2006, to February 22, 2010; and higher than 70 percent from February 23, 2010. The Board also remanded the issue of entitlement to a TDIU for further development. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in February 2012, the Court granted a joint motion of the parties and remanded the issue of entitlement to a rating in excess of 50 percent for PTSD prior to February 23, 2010, to the Board for actions in compliance with the joint motion. FINDING OF FACT The occupational and social impairment from the Veteran's PTSD more nearly approximated deficiencies in most areas than total occupational and social impairment for the initial evaluation period prior to February 23, 2010. CONCLUSION OF LAW The criteria for a disability rating of 70 percent, but not more, for PTSD have been met for the initial rating period prior to February 23, 2010. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran asserts entitlement to a rating in excess of 50 percent for PTSD prior to February 23, 2010. The Board will initially discuss certain preliminary matters and will then address the pertinent law and regulations and their application to the facts and evidence. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that or "immediately after" VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, the Veteran was provided all required notice in a letter mailed in April 2008. Although this letter was sent after the initial adjudication of the claim, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claim. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). The record also reflects that service treatment records (STRs) and all available post-service medical evidence identified by the Veteran have been obtained. The Board previously reviewed the record, determined that the VA examinations of record were inadequate, and remanded the case for the purpose of affording the Veteran an appropriate VA examination. The Veteran was afforded a VA examination in February 2010. The Board has reviewed the examination report and finds the originating agency substantially complied with the requirements articulated in the Board's remand; see Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has also been afforded a hearing before the Board. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claim; the Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the Veteran's claim. Legal Principles Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. When evaluating a mental disorder, the rating agency shall consider the frequency, severity and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on the social and occupational impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination. The rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. In relevant part, the rating criteria are as follows: A 50 percent rating is warranted 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 effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 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 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 both initial rating claims and normal increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Factual Background and Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected PTSD. The Board has found nothing in the historical record that would lead to the conclusion the current evidence of record is inadequate for rating purposes. Moreover, the Board is of the opinion this case presents no evidentiary considerations that would warrant an exposition of remote clinical histories and findings pertaining to the disability. In the case at hand, service connection for PTSD was granted in the June 2004 rating decision on appeal. A 30 percent schedular rating was assigned, effective May 9, 2003, the day after his separation from service. The originating agency ultimately assigned a 50 percent schedular rating, effective July 12, 2006, and a 70 percent schedular rating, effective from February 23, 2010. In September 2011, the Board granted an initial rating of 50 percent, but not more, prior to July 12, 2006, and denied entitlement to a rating higher than 50 percent from July 12, 2006, to February 22, 2010; and higher than 70 percent from February 23, 2010. After carefully reviewing the evidence of record, the Board concludes that the occupational and social impairment from the Veteran's PTSD for the period prior to February 23, 2010, more nearly approximates the deficiencies in most areas, required for a 70 percent rating, than the reduced reliability and productivity contemplated by a 50 percent rating. Service treatment records include a Referral for Civilian Medical Care dated April 16, 2003, stating the Veteran returned from Afghanistan with problems of stress/anger and depression. Current diagnosis was recurrent moderate major depressive disorder (MDD). Also diagnosed was attention deficit hyperactive disorder, predominantly inattentive type, by history. The Veteran was noted as being currently stable and not suicidal, homicidal or psychotic. He was placed on medication and his pending redeployment was cancelled. The Veteran presented to the VA urgent care clinic in August 2003 complaining of depression since returning from Afghanistan. During psychiatric evaluation the Veteran stated he found it very difficult to return to work because he found himself becoming increasingly weepy, irritable and depressed. He reported feeling overwhelmed by daily chores and occupational chores; he also reported sleep deprivation, nightmares, lack of energy and motivation, feelings of worthlessness, constant anger and suicidal ideation. During the interview the Veteran appeared to be sad and depressed, with blunted affect. Thought processes were intact, with no flight of ideas or looseness of association. There was no evidence of paranoia or delusions. The Veteran admitted to active suicidal ideation (SI) with plan, but judgment and insight were intact. The psychiatrist diagnosed major depression, single episode, rule out PTSD. The psychiatrist assigned a current Global Assessment of Functioning (GAF) score of 45, estimating the previous year GAF as 75. The Veteran was admitted to inpatient treatment, from which he was discharged in early September 2003. Thereafter, the Veteran presented to the VA urgent care clinic again in late September 2003, again complaining of depression with active homicidal and suicidal ideation. On clinical examination the Veteran was alert and oriented times three. The diagnostic impression was depression with homicidal and suicidal ideation. Per the treatment record, the Veteran was currently employed as a civil servant but was pursuing sick leave because he was having problems at his workplace. The Veteran was again admitted for inpatient psychiatric treatment, during which the attending psychiatrist noted that the Veteran had not improved significantly since the previous inpatient treatment. At the time of discharge from inpatient treatment in early October 2003, the attending psychiatrist continued the GAF score of 45 and noted the Veteran had no current suicidal plan or intent. The Veteran had a VA psychiatric examination in October 2003 in which the examiner noted the Veteran's military stressors and post-military treatment. The Veteran reported he was currently unemployed because he had not been able to get back to work since returning from Afghanistan. The Veteran reported symptoms of depression, avoidance, fatigue, tearfulness, loss of interest in activities, passive suicidal thoughts and intermittent psychomotor agitation. He also reported sleep disruption, trouble concentrating, hyperstartle and hypervigilance. During interview the Veteran presented as a mixture of dysphoric and anxious. He was alert and oriented. Speech was normal and there were no unusual mannerisms or tics. Mood was depressed and affect was restricted, with unlimited range. The Veteran denied current active suicidal ideation (SI) or homicidal ideation (HI). Thought process was coherent and goal-directed. Thought content was free of obsessions, compulsions, delusions or hallucinations. There was no evidence of concentration or memory disturbance. Judgment and insight were "pretty good" and there was no indication the Veteran was unable to handle his own funds. The examiner diagnosed MDD with PTSD symptoms and assigned a GAF score of 50-60. The Veteran submitted a Statement in Support of Claim in October 2003 stating he felt depressed most of the day and was overwhelmed by even the simplest tasks. Since his return from Afghanistan he had attempted to go to work on three occasions, but on each of those he had been unable to complete the entire day. While the Veteran was in Afghanistan a co-worker had tried to get him fired, and the Veteran entertained homicidal thoughts about that co-worker. The Veteran endorsed feelings of isolation and desire to build a bunker at his house in which he could shelter himself and his family. In November 2003 the Veteran submitted a letter asserting his request for sick leave had been denied by his employer (the Veteran was a civilian employee of the Army Reserve) and he had been assessed 80 hours of absence without leave. The Veteran had been notified by his employer that if he did not return to work he would be terminated, but the work environment was too stressful and the Veteran feared he would lose his job and his house. The Veteran's wife submitted a letter in December 2003 describing how the Veteran's fatigue and shortness of breath had required him to take an excessive number of sick days from work; her letter is silent in regard to psychiatric symptoms. The Veteran was once again admitted for VA inpatient treatment in December 2003 for ineffective coping with PTSD symptoms (irritability and anger, depression, hypervigilance and anxiety). In a history and physical (H&P) examination the Veteran reported having only worked four days since returning from Afghanistan, due to anger issues; he stated he had filed a workplace grievance against his employer, the Department of the Army. The record contains a behavioral assessment by a VA psychologist dated in December 2003, during the course of inpatient treatment, in which the Veteran reported intrusive recollections, avoidance behavior, diminished participation, feelings of detachment, anxiety, depression and irritability. The Veteran was observed to be adequately dressed and groomed, alert and oriented times four, and with speech relevant, coherent and goal-oriented. Mood was mildly depressed. The Veteran denied recent HI or SI. The Veteran denied delusions or hallucinations. Concentration, memory, abstraction, judgment and insight were all characterized as "fair." The psychologist diagnosed PTSD and assigned a current GAF score of 39. The Veteran's attending VA psychologist submitted a letter later in December 2003 characterizing the Veteran as having "moderately severe" PTSD that negatively impacted his personal relationships and work performance. She assigned a current GAF score of 42, up from a previous low of 39. The Veteran was eventually discharged from inpatient treatment in January 2004. In the discharge summary the psychologist stated the Veteran could return to his prehospitalization activities; while it appeared he could return to work this would need to be evaluated, and some form of light duty assignment might be preferable. The Veteran had a VA psychiatric examination in February 2004, performed by a panel consisting of a VA psychiatrist and a VA psychologist. The Veteran reported current problems of intrusive thoughts, agoraphobia and nightmares; he reported occasional passive SI and episodes of sadness but said these had improved with treatment. The examiners diagnosed severe PTSD with depressive symptoms and assigned a GAF score of 50-60. A VA outpatient note in September 2004 states the Veteran was currently working 20 hours per week in a hardware store and still looking for a job. The Veteran reported feeling much better after adjustment of his medications, although his sleep was still not good. The Veteran's mood was slightly depressed, without hallucinations or delusions. The examiner diagnosed recurrent major depression and assigned a GAF score of 60. A VA outpatient note in December 2004 states the Veteran was currently unemployed; he was unable to get to work on time because he had difficulty getting up in the morning. He endorsed frustration and anger, directed at his family. The examiner diagnosed recurrent depression and assigned a GAF score of 55. In April 2005 the Veteran's attending VA psychiatrist noted the Veteran currently had a part-time cleaning job. The veteran reported continued feelings of depression, not relieved by medication. He denied SI or HI. The psychiatrist continued the current GAF score of 55. In his Notice of Disagreement, received in May 2005, the Veteran asserted he had been removed from his previous fulltime job as unit administrator and had also lost jobs as assistant manager in a hardware store and as carpenter's assistant; he had only held the latter two positions for less than one month. A VA treatment note in June 2005 states the Veteran reported frustration because two federal departments appeared to be fighting regarding his employment. He reported stress due to health concerns of his wife and son, but he denied SI or HI. The Veteran attended therapy sessions at Valley Counseling and Consulting from May 2005 through September 2005, with general improvement in his ability to handle PTSD-related intrusive thoughts and responses. The Veteran continued to have hypersensitivity to loud noise and preoccupation with personal safety, although improved since treatment began. Of note, an August 2005 letter by a licensed clinical social worker (LCSW) at that facility states the current main concern was not the Veteran's PTSD symptoms but rather new stress caused by notification to the Veteran that he had been demoted in rank in the Army Reserve and was pending a less-than-honorable discharge. A VA treatment note in October 2005 states the Veteran continued to be out of a job. The Veteran reported poor sleep and lack of motivation; he also reported hypervigilance and paranoid delusions. He denied SI or HI. The examiner diagnosed recurrent major depression but he did not assign a current GAF score. In his substantive appeal, received in March 2006, the Veteran reported nightmares and irritability. He stated he had become disorganized and frequently became frustrated, and that he frequently wondered if life was worth living. The Veteran had a VA psychiatric examination in July 2006 in which he stated he continued to be unemployed due to history of tardiness and inability to get along with co-workers. He said his daily routine consisted of little other than being around the house, because he was not motivated to do more and also unable to complete tasks. He described three minor altercations with police during the previous year, all related to anger management problems. He reported nightmares, anxiety attacks with physical symptoms (heart racing), hypervigilance and feeling of being disenfranchised from society. On examination the Veteran was alert and oriented and his speech was "pretty normal." He denied active or passive SI or HI. Thought process was clear, coherent, logical and goal-oriented. Thought content was clear of obsessions, compulsions, delusions or hallucinations. Mood was irritated and affect was irritable and restricted. There was no evidence of any major concentration or memory disturbance. Judgment and insight were felt to be fair. The examiner diagnosed continued PTSD, history of depression and history of attention deficit hyperactivity disorder. The examiner assigned a current GAF score of 41-50. The Veteran presented to the VA clinic in February 2008 complaining of frustration in pursuing a number of VA claims (PTSD rating, chronic fatigue, asthma and joint pain). He endorsed a history of intermittent SI and denied current active SI but stated he would consider suicide if his house were lost to foreclosure. The clinician alerted other caregivers about the Veteran being a potential suicide risk. Thereafter, in March 2008 the Veteran denied current SI or HI. The Veteran underwent a battery of psychological tests by VA in April 2008, with emphasis on cognition due to possibility of previous traumatic brain injury (TBI). The Veteran endorsed memory impairment, irritability and sleep disturbance. He reported he tended to forget everything unless he wrote it down; he also stated that on some days he would be so incoherent as to be dysfunctional. During the interview the Veteran's mood was irritable, with congruent affect. Overall, his motivation and effort were so variable as to make the results of the evaluation unlikely to be a valid sampling of his current functioning. Nevertheless, orientation was grossly intact although his memory on testing was poor. The assessment was generally intact cognition with some impairment in executive functions (poor mental control and poor impulse control). He also scored in the "poor" memory range but he displayed variable cooperation and effort with evidence of symptom exaggeration; accordingly, cognitive deficiencies were more likely to be attributable to depression and PTSD than any sequelae of TBI. The Veteran testified before the Board in March 2009 that he had SI or HI within the past six months. He stated he was always angered by other people and seemed to always be angering other people as well. His anger had caused him to damage goods inside the house, and the police had been called to his house on several occasions. The Veteran had a number of fights in the past and accordingly tended to stay in the house of late. The Veteran's wife had to remind him to maintain adequate personal hygiene. The Veteran no longer communicated with his three sisters and ceased having any friends come over to the house. The Veteran had recurrent SI and carried a suicide hotline card in his wallet. In regard to employment, the Veteran was having trouble with his employer, the Army Reserve, even before his most recent deployment to Afghanistan because his fatigue symptoms had caused him to miss work. After he returned from Afghanistan he tried to get sick leave due to his PTSD symptoms, but the request was denied and he was eventually terminated for job abandonment. He was hired for awhile by a friend who owned a hardware store, but that job ended when the Veteran and his friend had a falling-out. VA outpatient treatment notes from February 2008 to February 2010 generally show the Veteran presenting as chronically reporting to therapy sessions late and fixated on current interpersonal problems. During the interview the Veteran was generally alert and oriented times three without evidence of psychosis or mania. The Veteran occasionally mentioned thoughts of suicide but consistently denied actual SI or HI. The Veteran had a VA psychiatric examination in February 2010 in which he reported depression, sleep problems, mood swings, anger and problems with memory and concentration. The examiner noted the Veteran was alert and oriented times three, but slow in mentation. He was coherent but it took him a long time to answer questions. His comprehension was also slow to the point of not grasping simple abstractions. There was no evidence of a thought disorder, but the Veteran's wife affirmed that he was unable to complete a project because he would become bogged down in progress. The Veteran reported active SI. The examiner noted the Veteran was not delusional and did not present a threat to others, but he showed severe cognitive deficits as well as poor insight and poor judgment. The psychologist diagnosed PTSD and major recurrent depression and assigned a current GAF score of 39. The Board acknowledges that the medical evidence of record does not reflect that the Veteran experienced all of the symptoms associated with the 70 percent schedular rating for the period prior to February 23, 2010. However, the Court has held that the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In the Board's opinion, the evidence for the period prior to February 23, 2010, shows that the social and occupational impairment due to PTSD more nearly approximated the deficiencies in most areas, required for a 70 percent rating, than the reduced reliability and productivity contemplated by a 50 percent rating. In this regard, of the symptoms associated with the 70 percent rating, during the period the Veteran showed difficulty in adapting to stressful circumstances (including work or a worklike setting), and homicidal and suicidal ideation. Additionally, the Veteran reported neglect of personal appearance and hygiene, and being irritable and easily provoked. With regard to impaired impulse control, the Board observes that the during this period the Veteran has reported minor altercations with police related to anger management problems, conflicts with other local officials and authorities, a history of getting into fights, and domestic incidents that involved the Veteran throwing or damaging property. The Board notes that he reported being sometimes "incoherent." With regard to social impairment, the Board notes that the Veteran has reported that his wife has threatened to leave. As for occupational impairment, the record reveals that the Veteran reported being fired or otherwise terminated from several jobs during the period prior to February 23, 2010, and he was unemployed during most of this period. Thus, for the period prior to February 23, 2010, the Veteran's social and occupational impairment due to PTSD more nearly approximated deficiencies in most areas. Finally, the Board has considered the GAF scores assigned during the period. The GAF score records the clinician's judgment of the individual's overall level of functioning, with 100 representing a high level of functioning and no psychiatric symptoms. See Quick Reference to the Diagnostic Criteria from DSM-IV, Washington, D.C., American Psychiatric Association, 1995. While the GAF score is not the sole basis for assigning a disability rating, it provides a clinical indicator of the patient's functional ability. In this case, GAF scores prior to February 23, 2010, have ranged from 39 to 60. A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or a major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 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). A GAF score of 51-60 represents 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 coworkers). Quick Reference, supra, pg. 46-47. Given that some of the Veteran's GAF scores during this period are indicative of "some impairment in reality testing or communication or a major impairment in several areas" and "serious symptoms or serious impairment," those scores support award of an initial rating of 70 percent from the date service connection was granted. However, the Board finds the occupational and social impairment during this period does not more nearly approximate the total impairment required for a rating in excess of 70 percent. Although the Veteran showed significant impairment he was consistently alert and oriented during examination. There is no psychosis and for the most part the Veteran has not been a threat to himself or to others. The evidence does not show the Veteran is incapable of self-care and he has not been determined to be incapable of managing his own finances. Moreover, throughout the period at issue, the Veteran had maintained his marriage. In addition, he employed at times. In sum, during this period of time, the disability was productive of deficiencies in most areas, but the social and occupational impairment did not more nearly approximate total. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Board has accordingly carefully considered the lay evidence of record to include the Veteran's testimony before the Board, his correspondence to VA, and his statements to various medical providers. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, even affording the Veteran complete competence and credibility in reporting his symptoms, he has not asserted - and the medical evidence does not show - that his service-connected psychiatric disability more closely approximated the schedular criteria for a 100 percent rating during the period under review when all of the pertinent evidence is considered. Accordingly, the Board concludes that the Veteran is entitled to an evaluation of a 70 percent throughout the period prior to February 23, 2010. Furthermore, there is no basis for staged ratings. Neither the lay nor the medical evidence establishes that the disability met the criteria for a rating in excess of what has been assigned at any time during the period prior to February 23, 2010. As such, the Board finds that a uniform disability rating is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a) (2012). In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here, as discussed above, the record shows that the manifestations of the disability and the occupational and social impairment from the disability are consistent with those contemplated by the applicable schedular criteria. Accordingly, the Board has concluded that referral of this case for extra-schedular consideration is not in order. ORDER The Board having determined that that Veteran's PTSD warrants a 70 percent disability rating, but not higher, for the initial rating period prior to February 23, 2010, the benefit sought on appeal is granted to this extent and subject to the criteria applicable to the payment of monetary benefits. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs