Citation Nr: 1309326 Decision Date: 03/19/13 Archive Date: 04/01/13 DOCKET NO. 05-09 623 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period of October 5, 1999, to July 22, 2010, in excess of 50 percent for the period of July 22, 2010 to November 17, 2011, and in excess of 70 percent thereafter. REPRESENTATION Appellant represented by: Larry Stokes, Agent WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from February 1976 to November 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which implemented the Board's March 2004 decision to award service connection for PTSD. The RO assigned a 30 percent disability evaluation for that disability, effective October 5, 1999. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in October 2007 and before a Decision Review Officer (DRO) in March 2011; transcripts of those hearings are associated with the claims file. This case was before the Board in December 2007, March 2010, and December 2010, when it was remanded for further development. That development ordered in those remands having been completed, the case has been returned to the Board at this time for further appellate review. During the pendency of the last remand, the RO staged the Veteran's PTSD disability evaluation, increasing it to 50 percent effective July 22, 2010, and to 70 percent effective November 17, 2011. This was done in July 2011 and August 2012 rating decisions. The Board has therefore recharacterized the issue on appeal in order to accurately reflect these decisions and awards of staged disability ratings. The Veteran's claim for entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is currently pending before the RO. See August 2012 statement. The Board, therefore, will not address that claim, but will allow the RO to complete its development and adjudication of that issue. FINDINGS OF FACT 1. Throughout the claim period, the Veteran's PTSD has been manifested by the following symptoms, which have generally been present to varying degrees of severity: depressed mood; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; impaired judgment; near-continuous depression affecting ability to function independently, appropriately and effectively; difficulty in adapting to stressful circumstances, such as work or a work-like setting; inability to establish and maintain effective relationships; suicidal ideation; impaired impulse control; and obsessional rituals that interfere with routine activities. 2. While the Veteran demonstrates some hallucinations and delusions, neglect of his personal hygiene, mild memory loss, and has expressed some homicidal thoughts, the Veteran's overall disability picture does not more closely approximate total occupational and social impairment. CONCLUSION OF LAW The criteria for an initial 70 percent evaluation, but no higher, for PTSD, beginning October 5, 1999, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's rating claim arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed. The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. (Examinations provide information needed to apply the rating criteria.) Moreover, his statements in support of the claim are of record, including testimony provided at hearings in October 2007 and March 2011 before the undersigned and a DRO. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim herein decided. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Background Review of the Veteran's VA treatment records reveals that in April 1999, he began seeking treatment for feelings of depression and worry about his children; such were moderate in severity at that time. He did not have suicidal ideations, and noted that he tended to overwork himself to avoid dealing with his issues. The Veteran was employed by the United State Postal Service (USPS) at that time. In a July 1999 treatment record, the Veteran was shown to have increased vigilance, constriction and anxiety over recurring memories of two tragic events that occurred while he was in service, including a helicopter crash where fellow servicemembers died and the Veteran was forced to standby helplessly and watch. The Board additionally notes that the Veteran was noted as having a lot of stress from his home life; the Veteran and his wife were not a "perfectly complementary relationship." Subsequent treatment records through the rest of 1999 and early 2000, generally demonstrate similar symptomatology. In February 2000, the Veteran began attending a non-combat PTSD support group through VA, which he appears to have attended throughout the appeal period. In an October 2000 letter from the Veteran's treating VA physician, Dr. D.B.P., the Veteran was diagnosed with PTSD with depressive features, which was chronic and considered severe. Dr. D.B.P. noted that the Veteran began having flashbacks and nightmares of a lieutenant's death while in service, which continued presently. He awoke from nightmares covered with sweat. Loud noises induced traumatic flashbacks. He began to isolate himself while in the Navy, and that pattern continued presently; the Veteran's work as a letter carrier facilitated his isolation behavior. The Veteran's naval service also was noted as leaving him with a deep distrust of others, especially those in authority. The Veteran's distrust continued and was noted as being almost to the point of paranoia. The Veteran was also noted as having difficulty controlling his anger and wanted to lash out when there is an exchange between him and a supervisor or coworker. The Veteran has learned to walk away from these situations and therefore is considered "odd" or "crazy." The Veteran married in August 1980, but has since that time grown distant from his wife; they slept in different rooms, did not communicate with each other, and did not have any intimate contact more than four or five times over the previous 15 years. The Veteran remained in the marriage at that time because of his children; although, he is not close with his children either, any closeness evaporated as they grew older. He did not engage in family occasions very much, and when he did, he was distant, numb and disengaged. He was noted as being anxious in crowds or when driving over a bridge. He was also preoccupied with death and thought about it all the time; he was also more depressed since the recent death of several friends. He was noted as being a letter carrier for 19 years with the USPS. He isolated himself and often had arguments or disagreements when he has contact with his coworkers. He had trouble controlling his temper and had to remove himself before becoming physical. Dr. D.B.P. noted that there was no indication of psychotic thinking either individually or during the group sessions; there were no indication of psychosis or delusional thinking and no history of substance abuse. The Veteran was noted as having a "miserable interpersonal and social life" since the traumatic incident in service. The Veteran has provided for his family and shown he can manage to remain gainfully employed for many years, "but only at great emotional expense and anxiety and detriment to his relationships with his family, especially his wife." The Veteran was assessed a GAF of 44. In November 2000, the Veteran underwent a VA examination for his PTSD. The Veteran reported that he had trouble getting along with his supervisors at the USPS; the Veteran was noted as being "a workaholic and controlling." The Veteran also reported martial conflict with his wife; she would not attend therapy or counseling. He also stated he did not want to get close to people, and disliked crowds. He was afraid of being judged; he said he was the family scapegoat and that others did not like him. He did not trust others and felt like he did not fit in. He also saw other people as "second rate." He recently was started on Zoloft and had improvement with that medication. The Veteran was noted as attending a PTSD group. On examination, the Veteran was shown to have "obsessional and controlling traits, and is a critical person himself. He uses a mental mechanism of splitting and has a prominent paranoid thinking. There is a long-standing anxiety or mistrust of authority and this was preceded by his father's own difficulties with authority." It was noted that the Veteran had recurring memories of the helicopter crash in which a lieutenant with whom he was friendly died. The examiner noted that the Veteran had some symptoms of PTSD, but failed to meet the full criteria at that time. In axis II, the Veteran was shown to have obsessional and paranoid personality traits. The Veteran was further noted as having distant relationships with all people, including his wife, with paranoia probably playing a major role. He was given a GAF score of 55. VA treatment records from August 2001 demonstrate that the Veteran sought a letter from Dr. D.B.P. for excused two weeks of sick leave, because he was "fearful that he [would] hurt someone at work if he does not take time off." A December 2001 letter from Dr. D.B.P. indicated that the Veteran was continuing to attend the non-combat PTSD therapy group. In a December 2001 statement, the Veteran indicated that he cannot fly in an aircraft, go swimming or form friendly relationships with people because of his traumatic incidents in service. He stated that he suffered panic attacks and cannot tell his family because they will think he is "crazy and unstable." He stated he was distant and uncaring towards his family at times, because he fears that he will lose them. He stated he has no friends, but that he becomes stronger when he attends meetings with others who share his fears and doubts. The Veteran's spouse also submitted a December 2001 statement. She stated that the Veteran was in a constant state of denial, and that he would do things to make her feel like she was crazy, including lying to her about whether he was viewing adult video tapes in the house. She indicated that the Veteran and she were no longer intimate and that he became cold and distant while in the service. She noted that he verbally abuses her, and actively tries to turn her children against her. She stated that the Veteran is constantly negative. She stated that he has no friends and takes his anger and frustration out on his family with verbal abuse "because he does not want to get close to us or no one." She noted that he has become more depressed and withdrawn from his family within the last year. In a June 2002 letter from a panel of three VA doctors, the Veteran was noted as meeting the full criteria for a diagnosis of PTSD. The Veteran was noted as having intrusive memories, flashbacks and nightmares. He avoided airplanes, water, or anything that he perceived as dangerous. He isolated himself from all social interaction and had a significant mistrust of others, which markedly interfered with his family, marriage and social interactions and produced significant employment impairment. His symptoms also included hyperarousal, anger, constantly feeling on edge, difficulty sleeping, and hypervigilance, as well as obsessional rumination and paranoia, which were classified as a personality disorder in the prior VA examination, but were noted as being symptoms of his PTSD by the panel. The Veteran was given a GAF score of 40 at that time. In an undated statement received approximately in January 2005, the Veteran indicated that he continued to attend group therapy sessions at VA, and that he was now enrolled at an anger management class at a Family Crisis Center, after he apparently had an incident that involved his son. The Veteran submitted paperwork that indicated that he had a contract for anger management classes and that he had filed for a protective order against his son, which required that his son not "abuse, threaten to abuse and/or harass" him. In the March 2005 substantive appeal, the Veteran stated that he and his wife were splitting and divorcing, that he had "hate for people," and thinks "of death constantly." An August 2005 letter from Dr. D.B.P. shows that the Veteran was advised to take several weeks off or work due to some stress he was experiencing at that time. It was noted that he took sick leave from August 2 to August 15. In October 2007, the Veteran testified before the undersigned. The Veteran stated during that hearing that he had been treated by Dr. D.B.P. at VA since 1998 for his psychiatric condition; he was prescribed Zoloft. The Veteran indicated that he was still employed as a letter carrier at that time. He said he felt paranoid and crazy at work. The Veteran indicated that he was not getting along with his supervisors at work, and that he felt like he was being singled out and picked on. He stated that he "just feel[s] like killing" his supervisor. He stated that he cannot stand any of his coworkers. He testified that he does not get along with anyone and tends to stay to himself. He reported getting into fights with people at work and has at least a daily confrontation with his coworkers. The Veteran also testified that he and his wife had been distant since he left service and that he will come home after work and "basically think about killing [his] son and [his] wife because them two-basically [he would] have a fight with all the members of [his] family, [his] immediate family." The Veteran repeated several times during the hearing that he would kill or hit someone in the head with a bat, or take some other violent action, against someone in his family if they said the wrong thing; he expressed a desire to divorce his wife and get away from her, because he needed to be by himself and could not be around anyone. The Veteran indicated that the court documents involving anger management and the restraining order involved a confrontation with his son that led to the police being called; another incident in which the police were called involved his wife, where he had knocked her tooth out. The Veteran further reported in his hearing that he suffered from memory loss, including words and names. A November 2007 letter noted that the Veteran was still attending group therapy for non-combat PTSD at VA at that time. In November 2008, the Veteran underwent a VA examination of his PTSD. During that interview it was noted that he was no longer married; it appears that the Veteran's wife died of cancer 3 months prior to the examination. The Veteran reported a history of marital and family strife that has mellowed over time. The Veteran had not been hospitalized for his condition. He was still taking Zoloft and attending his weekly group therapy session at VA. The Veteran reported daily, almost-severe symptoms, minimally helped by Zoloft that mainly calmed him down and reduced his nightmares. The Veteran reported having no social relationships because he did not like to be around people. It was noted that he had initiated a fight at work on April 15, which resulted in the Veteran being suspended from work for 2 weeks. The examiner noted that there was no impairment in thought processes or communications, or suicide attempts. The Veteran's activities of daily living were within normal limits. He was oriented in all areas. The rate of flow of his speech was normal and he did not have any panic attacks. The Veteran reported occasionally hearing a voice and thinks he hears a doorbell; he will get up to check the door and there is nothing there. The Veteran does not get 8 hours of sleep, but his nightmares do not occur very often. The Veteran rated his depression as 5 out of 10, though without his medication it spikes to 8 out of 10; he rated his anxiety the same as his depression. The examiner noted 10 critical times in his examination report: (1) Symptoms that have appeared since the last examination which was in 2004 and he rated the severity of his symptoms as nearly severe. (2) There have been no 30 day remissions since this examination. (3) He is in a PTSD group and he takes Zoloft. (4) He missed two months of work in the last year, solely due to PTSD symptoms. (5) He states that he has no social relationships. (6) No substance abuse. He does drink occasional wine. (7) No impairment in thought processes or communication. (8) His ability to maintain his activities of daily living within normal limits. (9) No other mental disorder found. (10) He manages his money okay. The Veteran was diagnosed with chronic PTSD and assigned a GAF of 63. The Veteran later submitted evidence confirming that in April 2008 he was suspended for two weeks for an incident involving physical contact with another coworker. The Veteran's VA treatment records from 1998 through 2011 consist generally of the Veteran's PTSD group therapy notes that do not give an individual assessment of the Veteran, though those documents do sometimes note that the Veteran related continued interpersonal problems, particularly with his family, during group sessions. In an October 2009 statement, the Veteran indicated that his wife died on July 22, 2008 and since then he has had increased feelings of guilt regarding their relationship for many years prior to her death. He stated that he suffers from memory loss and delusions, as well has having a feeling to kill himself because of blaming himself for causing her death. In that statement, the Veteran indicated that he was retiring from the USPS on November 30, 2009. The Veteran underwent another VA examination of his PTSD in April 2010. The Veteran reported a history of family counseling sessions three years earlier, and stated that he continued to attend the group therapy sessions weekly at VA; he was prescribed Zoloft. The Veteran reported still having nightmares and racing thoughts while on Zoloft, but felt that it was helping him a little bit. He further reported feeling frightened and scared, and not having the energy to do anything. He stated that he has nothing to look forward to, and constantly thinks about how things were with his wife before she died. The Veteran indicated that he still engaged in isolative behaviors and got into arguments with his children because "they don't listen to what [he] had to say." The Veteran was shown to be retired at that time and had been for a year and a half at that time. He reported that he was alone and liked being by himself, did not like crowds and had poor communication with his children. He stated that he did not have any friends and he did not trust anyone. The examiner diagnosed the Veteran with PTSD. The examiner noted that the Veteran's employment, activities of daily living and schooling were not currently affected by his symptoms; however, he was mildly affected in his routine responsibilities and physical health, and moderately affected in his family role, relationships, leisure activities, and quality of life. The examiner noted that the Veteran did not have an impairment of thought process or communication; delusions, hallucinations, or their persistence; or, current suicidal thoughts, ideation, plans or intent. The Veteran's behavior was appropriate. He had past suicidal thoughts. He was able to maintain his personal hygiene and activities of daily living and was oriented to person, place and time. The Veteran indicated that he has memory loss, such as forgetting people's names, why he went to certain places, or forget what he was talking about when he is speaking. He did not have any obsessional or ritualistic behaviors, his rate and flow of speech were normal and he did not have any panic attacks. He had impaired impulse control, presence of anxiety, depression, and depressed mood, and sleep impairment, including nightmares. The examiner noted that the severity of the Veteran's symptoms was medium, but his symptoms were chronic and continuous. He was not assessed as unemployable at that time. He was diagnosed with PTSD and major depressive disorder, and assessed a GAF of 54. The examiner noted that the Veteran's major depressive disorder was secondary to his PTSD and that he was unable to delineate symptoms of each mental disorder without speculation. Also in June 2009 and April 2010, the Veteran had a psychiatric consultation with VA. Those psychiatric consultations generally showed similar symptomatology as described in the April 2010 VA examination. Those consultations assigned GAF scores of 55. The Veteran's daughter and friend, G.H., submitted statements in September 2010 regarding the Veteran's symptomatology. Since his wife's death, the Veteran has been more anxious and ruminates about his death. He also has been seen by his daughter to sit for hours on end and talking to himself about dead people, particularly his wife. The Veteran had a psychiatric consultation with VA in January 2011. During that consultation, the Veteran reported many of the same symptoms documented above. He was casually dressed with good hygiene. He had normal psychomotor activity, was cooperative with fair-poor eye contact. His speech was normal in rate, volume and tone, and he had a logical and goal-directed thought process. He was moody and had been for years. He had a full range of affect. He reported hearing voices of dead people, particularly his wife, and indicated that he had immense guilt associated with deaths in his life. He was paranoid and seemed preoccupied with whether he was going to die a violent death. He denied being helpless, worthless or hopeless. He had difficulty falling asleep and maintaining sleep. He did not have any manic symptoms. His cognitive functioning was grossly intact and he was oriented to person, time and place. He had fair insight and judgment. He denied any active suicidal or homicidal ideations, though he had past suicidal thoughts. The Veteran was assessed as a low suicidal risk. He got angry and has talked about hitting his son "upside the head," but his PTSD group was helping him not to act on those thoughts. The Veteran was assigned a GAF of 50. In March 2011, the Veteran had a hearing before a DRO at the RO. During that hearing, the Veteran stated that he could not be around and did not get along with people, had nightmares, was restless, was "delusional," and "fear[ed] for [his] life." He reported that he was always angry and wanted to strike out at his kids, and that it seemed like a police officer was always at his house because of a complication he created. He testified he did not like being in crowds or feeling "boxed in." The Veteran stated he drank "a lot of wine" and smoked marijuana. He testified that he still attended the PTSD group therapy sessions once a week at VA and continued to take Zoloft. He stated that he has deceased people talking to him "constantly" and that he talks with them and carries on conversations with them. He had his daughter do his shopping for him and he almost never left the house, like he was "scared something, something [was] going to happen to" him. He stated that he had difficulty sleeping and had nightmares; he wakes up feeling as if he has not slept at all. He finally testified that he felt like he got worse after the death of his wife. The Veteran underwent a VA examination for his PTSD in April 2011. The Veteran's complaints were similar to those described above. He reported physical fights with his sons, which have led to the Veteran having to serve legal papers to each of them to move out of his house. The Veteran reported that he retired in 2009 after 29 years at the USPS; he stated he stopped working because his wife died and he felt like there was no reason to move on, he was fighting with his coworkers, had medical problems and was having problems sleeping. The Veteran reported that he isolated himself, was capable of basic activities of daily living, and was able to meet family responsibilities. On examination, the Veteran was casually and neatly dressed, and had his eyes closed throughout most of the examination. He did not have an impairment of his thought process or communication. He was shown to have delusions and hallucinations, the examiner noting that he talked to military friends and wife who have all passed away and that it has happened for three years and occurs all the time. He will also see his wife's face on other people's faces or in trees or bushes. The Veteran's behavior during the session was appropriate. He had current suicidal ideations, including thoughts about hurting himself "pretty often" and has thoughts about what he would do to kill himself; the examiner noted a three-year history of suicidal ideation coinciding with the Veteran's wife's death, though he has never attempted suicide. The Veteran stated that he took a shower once a week and changes or washes his clothes once or twice a week, though the examiner noted that he appeared clean and did not have an odor. The Veteran had problems recalling the correct date, noting that it was April 9, 2011, when it was really April 13, 2011. The Veteran stated that he forgets names, faces, and things that he has read or what he went to the store for. He did not have any obsessional rituals or panic attacks. His speech flow and rate were normal. The Veteran had depression, depressed mood and anxiety, particularly when thinking about death; he gets nervous and breathes quickly. He said he had no feelings, does not feel joy, happiness, or have any energy or motivation. He has racing thoughts and poor concentration. The Veteran has impaired impulse control and difficulty falling asleep. The examiner noted that the severity of the symptoms was moderate, and his symptoms were chronic and continuous. The Veteran was diagnosed with PTSD and moderate major depressive disorder. The Veteran was not unemployable and was given a 54 GAF score. Finally, the Veteran underwent a VA examination of his PTSD in November 2011. The examiner noted that the Veteran has been diagnosed with PTSD and that his symptoms have led to chronic conflict with his children and social isolation. The Veteran had a successful career prior to his wife's death, and that physical ailments impeded him from currently seeking full-time work. Specifically, the examiner stated, "While the Veteran's symptoms of depression have impeded his motivation to secure and maintain employment[, his] symptoms of PTSD, which fall within the moderate range, do not at least as likely as not prevent him from securing or maintaining substantially gainful employment." The examiner noted that the Veteran's functional impairment was most closely summarized as being "occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." The Veteran reported continued strife with his children, including physical confrontations. He stated that he was "lonely, bored and just thinking that [he'd] be better off dead." He has reported this problem had worsened since his wife passed away. He continued to attend the PTSD group therapy at VA once a week and to take Zoloft. He endorsed severe irritability, short-term memory loss, and suicidal ideation with a vague plan to drown or shoot himself. The examiner noted that the following symptoms were present at that time: depressed mood; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; impaired judgment; difficulty establishing and maintaining effective work and social relationships; inability to establish and maintain effective relationships; suicidal ideation; and, obsessional rituals which interfere with routine activities. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran has been awarded a 30 percent evaluation for his psychiatric disorder, for the period of October 5, 1999 to July 22, 2010; a 50 percent evaluation from July 22, 2010 to November 17, 2011; and a 70 percent disability evaluation for his PTSD beginning November 17, 2011. These disability evaluations were assigned under 38 C.F.R. § 4.130, Diagnostic Code 9411. Diagnostic Code 9411 is governed by a General Rating Formula for Mental Disorders. Under the General Rating Formula, a 30 percent rating is warranted for PTSD for 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 (1999-2012). 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 and maintaining effective work and social relationships. Id. 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 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. Id. 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; 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. Id. When evaluating the level of disability from a mental disorder, 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 (2012). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF score of 61 to 70 indicates some mild symptomatology (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, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2012). Based on evidence of record, the Board finds that the Veteran's psychiatric disorder warrants a 70 percent evaluation beginning October 5, 1999. The Board finds that the Veteran has demonstrated symptomatology since that time that demonstrates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. Throughout the claim period, the Board notes that the following symptoms have been generally present to varying degrees of severity: depressed mood; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; impaired judgment; near-continuous depression affecting ability to function independently, appropriately, and effectively; difficulty in adapting to stressful circumstances, such as work or a work-like setting; inability to establish and maintain effective relationships; suicidal ideation; impaired impulse control; and, obsessional rituals which interfere with routine activities. The Board notes that early on the Veteran's symptoms included physical altercations with his family and coworkers, including suspension for fights at work as well as general conflict in the home with his wife prior to his death and his children throughout the appeal period. Such demonstrates impaired impulse control, an inability to establish and maintain effective relationships, and difficulty in adapting to stressful circumstances. The Board also notes that the Veteran's obsessional rituals have also been more or less present throughout the claim period, and such have been associated with his PTSD symptoms in the June 2002 letter. More recently, particularly after the his wife's death, the Veteran's symptomatology picture included suicidal ideations, and near-continuous depression affecting his ability to function independently, appropriately and effectively, while still having impaired impulse control and anger issues. Throughout the claim period, the Veteran has demonstrated a pattern of severe social isolation and consistently expressed a desire to be alone and by himself. He has also been found to have GAF scores that at times reflected severe impairment. At other times the scores have reflected moderate impairment, but the symptoms he has experienced appear to be akin to the kind of symptoms typical of the criteria for a 70 percent rating. He additionally described neglecting his personal hygiene in the April 2011 VA examination. The Board, however, does not find that there is a total occupational and social impairment in this case. The Veteran was able to work up until he retired in November 2009. While the Board notes that there were some definite impairments due to his PTSD symptoms, the Veteran was able to maintain his occupation as a letter carrier. Moreover, the Veteran is never shown to have any impairment of thought processes or communication throughout the claim period; he was described as having a normal speech rate, flow and volume in all interviews, and was shown to be logical and goal-directed in his thought processes. The Veteran had numerous physical encounters with his children and with people at work, and there is some evidence that he began to ruminate about death, to see his dead wife's face in objects or other people, and to talk with dead people, particularly his wife, after her passing. He also is noted as stating several times, particularly in his hearings on appeal, that he wished or thought about killing his children, his wife, or coworkers at various times. The Board acknowledges that such behavior, both before and after his wife's death, could be considered "odd" or "inappropriate" behaviors, and could demonstrate both persistent hallucinations and delusions and persistent danger to himself or others, which would rise to the severity of total occupational and social impairment. The Board nevertheless notes that the Veteran's behavior was noted as being appropriate at all of his VA examinations and consultations throughout the claim period. Additionally, while the Veteran is shown to have suicidal thoughts and a vague plan most recently, he is also assessed as being a low suicide risk. Moreover, while the Veteran states that he wishes to kill particular people, including his sons, the Veteran has never acted in such a manner that would precipitate any taking of life. In fact, since stating that he had those homicidal feelings, the Veteran has been in countless physical and verbal altercations with his children, particularly his sons, and never acted on those thoughts. The Board recognizes that the Veteran is a severely angry and agitated person who lashes out in a physical manner; however, the current evidence of record does not demonstrate that he is in a persistent state of being a danger to himself or others around him. The Board further acknowledges that the Veteran appears to have some issues with personal hygiene maintenance, as per his lay statements on examination. Those statements, however, do not appear to match the Veteran's consistent casual and neat presentation of himself when in public. Thus, the Board notes that the Veteran may have motivation issues that lead to neglect of his personal hygiene, but that he does not have an inability, however intermittent it may be, to perform his activities of daily living, including maintenance of his personal hygiene. In fact, when the scope of activities is broaden to encompass all activities of daily living, the Veteran is consistently shown throughout the appeal period to be more than adequately able to perform those activities on an independent, appropriate and effective basis. Finally, the Board notes that the Veteran is not shown to have any disorientation to time or place. While he got the date wrong by 4 days at the April 2011 examination, the Board notes that such is evidence of the Veteran's mild memory loss, which he noted included forgetting names and dates, what he just read or what he went to the store for. The most recent VA examiners noted that such memory loss was not particularly severe, but rather mild in severity. The Board notes that such memory loss does not rise to the level of memory loss necessary for total occupational and social impairment. In short, the Board acknowledges that the Veteran has some features and symptoms suggestive of total occupational and social impairment and a 100 percent disability evaluation under the General Rating Formula, such as apparent delusions/hallucinations of hearing and talking to dead people. However, the Board notes that the severity of the Veteran's symptomatology and entire disability picture does not disclose total occupational and social impairment, but rather more closely reflects occupational and social impairment with deficiencies in most areas throughout the claim period. Such equates to a 70 percent disability rating. Accordingly, the Board therefore finds that a 70 percent evaluation, but no more, is warranted, beginning from October 5, 1999. See 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. The Board must also determine whether the schedular evaluation is inadequate, thus requiring that VA refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation is adequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected PTSD, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorder. As the rating schedule is adequate to evaluate the disability, referral for extraschedular consideration is not in order. Finally, the Board has also considered whether a total disability rating based on individual unemployability due to service-connected disability (TDIU) of PTSD is warranted at this time. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (noting that TDIU is part and parcel of a claim for increase). In order for a finding of TDIU to be made, the Veteran must be unable to secure and maintain substantially gainful employment as a result of his service-connected disability, without regard to age or nonservice-connected disabilities. See 38 C.F.R. § 4.16(a) (2012). In this case, the Board notes that the evidence of record, specifically in regards to his PTSD, the most recent VA examiner noted that the Veteran's PTSD symptoms did not preclude him from obtaining and maintaining substantially gainful employment, but rather affected his motivation to do so. The Board finds that the Veteran's assigned 70 percent evaluation contemplates the difficulties in that motivation and there is no evidence of record that the Veteran's PTSD symptomatology is solely responsible for unemployability; in fact, the Board notes that the Veteran stated that his physical ailments also impede his ability to work. Thus, at this time, the Board must conclude that the Veteran's PTSD alone does not preclude him from obtaining and maintaining substantially gainful employment and that an award of TDIU based on PTSD is not warranted. (The Board does however note, as stated in the Introduction, that there is a TDIU claim pending, which requires consideration of all of his service-connected disabilities-not solely his PTSD-and which is currently before the RO. The Board's above finding with regards to TDIU should not be taken as relieving the RO of its obligation to adjudicate that claim based on multiple service-connected disabilities.) In reaching the above conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for a rating higher than 70 percent, that doctrine is not helpful to the Veteran. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER An initial 70 percent evaluation, but no higher, for PTSD, beginning from October 5, 1999, is granted, subject to the regulations controlling the payment of monetary benefits. _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs