Citation Nr: 1313727 Decision Date: 04/24/13 Archive Date: 05/03/13 DOCKET NO. 04-38 018 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to an increased rating for posttraumatic stress disorder, initially evaluated as 30 percent disabling prior to September 5, 2008, 50 percent disabling from September 5, 2008 to August 9, 2012, and 70 percent disabling thereafter. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from December 1968 to June 1970. This case originally came before the Board of Veterans' Appeals (Board) on appeal of a December 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. In that decision, the RO granted service connection and a 30 percent evaluation for posttraumatic stress disorder, effective from July 24, 2003, the date of receipt of the Veteran's claim. In September 2007, the Veteran's case was remanded to the RO for additional development. Subsequent to that remand, the Board, in a decision of December 2009, denied entitlement to an initial evaluation in excess of 30 percent for service-connected posttraumatic stress disorder. In a Memorandum Decision of September 2011, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's December 2009 decision denying entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder, and, in so doing, remanded the Veteran's case to the Board for action consistent with the Memorandum Decision. In June 2012, the Veteran's case was once again remanded to the RO for additional development. Subsequent to that remand, the Appeals Management Center (AMC), in a rating decision of December 2012, granted a 50 percent evaluation for service-connected post-traumatic stress disorder effective from September 5, 2008. In that same rating decision, the AMC granted a 70 percent evaluation for posttraumatic stress disorder effective from August 9, 2012. The case is now, once more, before the Board for appellate review. FINDINGS OF FACT 1. Prior to September 5, 2008, the Veteran's posttraumatic stress disorder symptomatology, when compared to symptoms listed in the Rating Schedule, was not manifested by occupational and social impairment, with reduced reliability and productivity due to such symptoms as: a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; 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; and/or difficulty in establishing and maintaining effective work and social relationships. 2. During the period from September 5, 2008 to August 9, 2012, the Veteran's posttraumatic stress disorder symptomatology, when compared to symptoms listed in the Rating Schedule, was not manifested by 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); spacial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and/or an inability to establish and maintain effective relationships. 3. Since August 9, 2012, the Veteran's posttraumatic stress disorder symptomatology, when compared to symptoms listed in the Rating Schedule, has not been manifested by total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communications; 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; and/or memory loss for the names of one's close relatives, own occupation, or own name. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent for posttraumatic stress disorder prior to September 5, 2008 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an evaluation in excess of 50 percent for posttraumatic stress disorder during the period from September 5, 2008 to August 9, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 3. Since August 9, 2012, the Veteran's posttraumatic stress disorder has not met the criteria for an evaluation in excess of 70 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In the case at hand, inasmuch as service connection, an initial rating, and an effective date have been assigned, the notice requirements of 38 U.S.C.A. § 5103 (a) (West 2002) have been met. Moreover, VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claim, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. Increased Rating In reaching this determination, the Board has reviewed all the evidence in the Veterans' claims file, which includes his multiple contentions, as well as both VA treatment records and examination reports. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claim, and what the evidence in the claims file shows, or fails to show, with respect to that claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran seeks an increased evaluation for service-connected posttraumatic stress disorder. In pertinent part, it is contended that manifestations of that disability are more severe than presently evaluated, and productive of a greater degree of impairment than is reflected by the respective 30, 50, and 70 percent schedular evaluations now assigned. Disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § Part 4 (2012). Where there is a question as to which of two evaluations apply, the higher evaluation will be assigned where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). While the Board must consider the Veteran's medical history as required by various provisions under 38 C.F.R. Part 4, including 38 C.F.R. § 4.2(c) [see Schafrath v. Derwinski, 1 Vet. App. 589 (1991)], the degree of impairment resulting from a service-connected disability is a factual determination, with the Board's primary focus in such cases being upon the current severity of the service-connected disability. See Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the Francisco rule does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following the award of service connection for the disability in question. Rather, at the time of the initial rating, separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. Accordingly, the analysis in this decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). Ratings are to be based as far as practicable upon the average impairment of earning capacity, with the additional proviso that the Secretary shall, from time to time, readjust the Schedule of Ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits, or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in 38 C.F.R. § 3.321 (2012) an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture, with such related factors as a marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2012). In the case at hand, in a rating decision of December 2003, the RO granted service connection (and a 30 percent evaluation) for posttraumatic stress disorder, effective from July 24, 2003, the date of receipt of the Veteran's claim. The Veteran voiced his disagreement with the assignment of that 30 percent evaluation, with the result that, in a subsequent rating decision of December 2012, the RO awarded a 50 percent evaluation for posttraumatic stress disorder effective from September 5, 2008, and a 70 percent evaluation for that same disability, effective from August 9, 2012. In a Vet Center Social Survey dated in mid July 2003, the Veteran was described as neat and clean in appearance, with good hygiene, and both friendly and cooperative. According to the examiner, the Veteran displayed no unusual mannerisms or movements, nor was there any evidence of psychotic symptomatology. When further questioned, the Veteran complained of occasional nightmares about Vietnam. Further noted were problems with sleep apnea. When questioned, the Veteran complained of "intrusive thoughts about the military." Moreover, he displayed "a lot of avoidance behaviors." According to the Veteran, he was often irritable, and found himself "getting angry at little things." The Veteran's affect was described as sad, and his mood depressed. Significantly, according to the Veteran, he should never have retired. On mental status examination, the Veteran was oriented to place and person, though, apparently, not to time. His memory appeared to be within normal limits, though he experienced some difficulty with serial 7's, suggestive of problems with focus and attention. At the time of evaluation, the Veteran was able to interpret proverbs. However, his insight into his problems appeared poor. According to the examiner, the Veteran clearly suffered from a number of traumatic incidents while in Vietnam, which resulted in "some significant" posttraumatic stress disorder symptoms. At the time of a VA psychiatric examination in November 2003, the Veteran indicated that he had worked at Kodak both before and after his military service. Reportedly, the Veteran had retired from that job the previous year after having worked for 35 years. Significantly, although the Veteran reported difficulties at work with his supervisors, his period of employment was continuous. When questioned, the Veteran complained of emotional problems, and indicated that his temper had become increasingly worse. He spoke in a reserved tone, but with a strained voice, and noted that he became "very jumpy" when disturbed by loud noises. Moreover, by the Veteran's own admission, he tended to be hypervigilant. On mental status examination, the Veteran's attitude was described as one of resignation and mild despair. Rapport was adequately established, though at times, the Veteran appeared pressured in offering information. Significantly, at the time of evaluation, there were no abnormalities in gross motor function, though random fine motor activity was strongly suggestive of anxiety. The Veteran's mood was dysthymic, and his affect depressed, with an attitude characterized by mild despair and feelings of helplessness or futility. According to the examiner, the Veteran appeared to experience mild, though significant, anxiety. Depression was also noted, though there were no manifestations of guilt, grief, or mania. When questioned, the Veteran reported considerable, and at times intrusive, anxiety in social situations, in particular, when in large groups or in the presence of "unexpected noises." Moreover, the Veteran was notably tense and anxious throughout the interview, though he appeared able to control it reasonably well. The Veteran's speech and language functions were fully intact and unimpaired. Thought processes were similarly unimpaired, and there was no evidence of any delusions, hallucinations, or aberrations of thinking. While the Veteran did appear to experience some ruminative thinking regarding his experiences in Vietnam, it was unclear whether these were specific to the evaluation, or more endemic to the Veteran's functioning. While the Veteran reported what might be considered paranoid delusions to others "by report," these were not present during the interview. At the time of evaluation, the Veteran was fully oriented to time, place, and person. Cognitive dexterity was described as somewhat limited, and executive cognitive functions appeared mildly impaired as related to the Veteran's speed of thought and information processing. According to the examiner, the Veteran's capacity for abstract thinking was intact, though not sophisticated. Simple analogies and proverbs were easily understood, though the Veteran experienced difficulty with more integrative, complex material. At the time of examination, the Veteran's remote memory was intact, and he was able to recall both recent events and activities in his life. Short term memory was also intact, though immediate recall was somewhat limited by what appeared to be distractibility. Judgment appeared to be intact some of the time, though occasionally compromised by impulsivity, frustration, and general anxiety. According to the examiner, the Veteran's insight appeared to be "developing," though it was not a well-established aspect of his thinking. Significantly, at the time of examination, there was no evidence of either homicidal or suicidal ideation. The pertinent diagnosis noted was posttraumatic stress disorder, with a Global Assessment of Functioning Score of 55. In a Vet Center treatment record dated in April 2004, the Veteran indicated that he had been "managing his posttraumatic stress disorder without significant exacerbation." Further noted was that the Veteran appeared to be applying what he had been learning, and was "currently managing his symptoms." In a Vet Center treatment record of October 2004, the Veteran's posttraumatic stress disorder was described as "severe," with the Veteran continuing to struggle with anger and rage, as well as paranoia around other people. A VA record of hospitalization covering the period from mid February to mid March 2005 reveals that the Veteran was hospitalized at that time for what was described as an "exacerbation" of posttraumatic stress disorder symptomatology. At the time of admission, the Veteran reported experiencing increased anger, nightmares, startle response, hypervigilance, intrusive thoughts, and sleep disturbance since retiring three years earlier. During hospitalization, the Veteran participated in both individual and group psychotherapy, and received medication management and peer support. Reportedly, the Veteran dealt with his anger and anxiety issues, and began to understand the relationship of his symptoms to his problems. By the time of discharge, the Veteran appeared to have gained from his stay on the posttraumatic stress disorder unit. He was cooperative, and fully participated in all functions and activities. While the Veteran initially demonstrated some difficulty in managing anger and interpersonal interactions, he successfully utilized supports and developed skills to address these concerns. The pertinent diagnosis noted was posttraumatic stress disorder, with a Global Assessment of Functioning Score of 41 at both admission and discharge. In a rating decision of May 2005, the Veteran was awarded a temporary total evaluation of 100 percent based on hospitalization for posttraumatic stress disorder of over 21 days. On VA psychiatric examination in June 2005, it was noted that the Veteran was in a weekly group, but that he also attended day treatment one day a week. Further noted was that, while the Veteran had reportedly experienced difficulties at work while at Eastman Kodak, his period of employment had been "continuous." According to the examiner, the Veteran was able to conduct all activities of daily living without difficulty, though his wife took care of most of the family finances. Moreover, by the Veteran's own report, he had a "good relationship" with his immediate family members. On mental status examination, the Veteran was somewhat tremulous, and he startled suddenly at the sound of an ambulance siren. His personal hygiene was good, while his attitude was unremarkable and generally cooperative. Rapport was described as adequately established for the intended purpose of the assessment. As was the case during the course of the Veteran's last evaluation, he was once again somewhat angry and embittered, as well as anxious. The Veteran's mood was described as dysphoric, and he appeared to feel entitled to, and deeply ensconced in, such mood and affect. Significantly, the Veteran appeared to experience some grief regarding certain aspects of his combat experiences, and became intermittently emotionally labile, with an inappropriate affect at moments of heightened anger and embitterment. The Veteran's speech was unremarkable in all respects, and both expressive and receptive language were intact. Verbal productivity was described as average, and the Veteran's vocal tone and quality were within normal limits. At the time of examination, the Veteran's speech was relevant, coherent, and goal-directed. According to the examiner, the Veteran did not appear to suffer from visual or auditory hallucinations, or any other form of perceptual or cognitive distortion. Moreover, there were no other disturbances of thought process or content, with the exception of some mild persecutory and grandiose ideation at times of emotional arousal. Noted at the time of examination was that the Veteran was oriented to place and person. While according to the Veteran, he did not know the date, the examiner felt this might very well not be true. The Veteran's capacity for abstract thinking was described as probably consistent with his intellect. While the Veteran's remote memory appeared to be somewhat impaired, his short-term memory appeared intact. According to the examiner, while the Veteran's immediate memory might be "markedly impaired," malingering could not be ruled out. The Veteran's insight was described as lacking, and he appeared to have a very "concretistic" and overdetermined understanding of the role of trauma in his problems. At the time of examination, the Veteran's judgment appeared practical and intact. While suicidal ideation appeared to be periodically and recently experienced, the Veteran denied any plans upon which he had acted in the past. Significantly, at the time of examination, the Veteran denied any problems with homicidal ideation. The pertinent diagnosis noted was once again posttraumatic stress disorder, with a Global Assessment of Functioning Score of 55. Significantly, according to the examiner, the Veteran's clinical condition was "substantially unchanged" from when he was last seen in terms of social, interpersonal, and related problems. During the course of VA outpatient treatment in mid June 2005, it was noted that the Veteran remained in posttraumatic stress disorder counseling at the local Vet Center, and that he had started to attend the VA day treatment center. When questioned, the Veteran voiced general satisfaction with his medication. Significantly, according to the Veteran, with that medication, his mood was good, and he did not find himself irritable or engaging in "rage episodes." On mental status examination, the Veteran's overall presentation was unremarkable. He related fairly well, and did not appear to be irritable, angry, distressed, or panicky. At the time of subsequent VA outpatient mental health treatment in August 2005, the Veteran reported some decrease in anger and irritability. On mental status examination, the Veteran's affect was described as "mildly blunted," though not markedly so. Moreover, the Veteran did not appear distressed, agitated, helpless, hopeless, or morbidly depressed. During the course of VA outpatient treatment in September 2005, the Veteran indicated that he had volunteered at his church at least once per week during the period from August 17 to September 4, 2005. While the Veteran indicated that he had not volunteered for the past two weeks due to an exacerbation of his posttraumatic stress disorder, he intended to "get back to it," given that it "really helped him and they needed the help." In a VA outpatient treatment note dated in late January 2006, it was noted that the Veteran attended and participated in day treatment activities. Further noted was that the Veteran enjoyed the socialization opportunity, as well as enhanced self-esteem, increased community resource awareness, and increased motivation. Significantly, the Veteran had developed constructive leisure skills, and was "feeling better" since his change in medication. During the course of VA outpatient treatment in February 2006, the Veteran indicated that he often found himself "irritable and on edge." However, with his medication change, he was feeling less jumpy and on edge. On mental status examination, the Veteran's affect was described as "less blunted" than it was on a prior occasion. Moreover, he related somewhat better, and did not appear to be irritable, anxious, panicky, or distressed. During the course of VA outpatient treatment in mid May 2008, the Veteran denied any history of suicide attempts, and similarly denied any recent or current suicidal ideation. On September 5, 2008, an additional VA psychological examination was accomplished. At the time of examination, it was noted that the Veteran had worked at Eastman Kodak both before and after his military service, having retired from that employment after 35 years. While according to the Veteran, when working, he experienced some difficulties with his supervisors; his period of employment had nonetheless been continuous. According to the examiner, during the course of the evaluation, the Veteran was very anxious and garrioulous, at times speaking at great length about matters of little or passing consequence. Moreover, according to the examiner, the Veteran appeared to be "over reporting" symptoms," responding in a manner predicated upon fulfilling the symptoms about which he was being asked. When questioned, the Veteran indicated that he attended anger management training, though he had not recently been involved in any physical altercations. Activities of daily living skills were reportedly intact, though according to the Veteran, he was in need of occasional reminders to maintain his personal hygiene. According to the examiner, the Veteran's social and interpersonal functioning were mildly to moderately disturbed. However, given that he was retired, his occupational functioning could not be assessed, though it was not considered an issue at the present time. On mental status examination, the Veteran's personal hygiene was adequate, though he was somewhat nervous throughout the interview. According to the examiner, the Veteran's attitude was unremarkable and generally cooperative, and rapport was adequately established for the intended purpose of the assessment. Noted at the time of examination was that the Veteran continued to present as angry and dysphoric in mood, with an affect which was primarily depressed, as well as anxious and angry. The Veteran's speech was somewhat dysfluent, representing a change in the status of that function since the time he was last seen. Expressive and receptive language were intact, and verbal productivity was average, with a voice tone and quality which were within normal limits. At the time of evaluation, the Veteran's speech was coherent, though at times rambling, and lacking in relevance and goal direction. According to the examiner, the Veteran did not appear to suffer from visual or auditory hallucinations, or, for that matter, any other form of perceptual or cognitive distortion. Moreover, with the exception of continued mild persecutory and grandiose ideation at times of emotional arousal, there was no evidence of any disturbance of thought process or content. At the time of examination, the Veteran was oriented to time, place, and person. His capacity for abstract thinking was described as "probably consistent" with his intellect, and while his remote memory appeared to be intact, both short term and immediate memory now appeared to be impaired, representing a change from when he was previously seen. The Veteran's insight continued to be lacking, and once again, he appeared to have a very concretistic and overdetermined understanding of the role of trauma in his problems. The Veteran's judgment was practical and intact, and while suicidal ideation appeared to be periodically and recently experienced, the Veteran had no specific plans or actions directed at self harm. In similar fashion, while homicidal ideation was reported, the Veteran acknowledged no intent or plan. The pertinent diagnosis noted was posttraumatic stress disorder, with a Global Assessment of Functioning Score of 51. During the course of VA outpatient treatment in early July 2009, the Veteran indicated that he was satisfied with his medications, and found them "quite helpful" with his mood, irritability, and sleep. On mental status examination, the Veteran was alert, calm, pleasant, and composed. Significantly, according to the examiner, while when last seen in December 2008, he was described as "slightly annoyed," this was not evident at the present time. Rather, the Veteran's overall presentation was unremarkable, with him appearing neither anxious nor depressed. As of the time of a recent VA psychological examination on August 9, 2012, the Veteran described many symptoms associated with posttraumatic stress disorder, including a tendency to isolate and not make friends, or develop close relationships. Moreover, according to the Veteran, he was at times hypervigilant, with a "startle reflex," and a tendency to become angered and somewhat hostile when challenged. When questioned, the Veteran complained of recurrent distressing dreams of previous events. Also noted was some physiological reactivity on exposure to internal or external cues. The Veteran complained of difficulty falling asleep, as well as irritability or outbursts of anger, hypervigilance, and an exaggerated startle response. On mental status examination, there was evidence of suspiciousness, as well as chronic sleep impairment. Also noted was impaired judgment, in conjunction with disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. Moreover, according to the examiner, there was evidence of an inability to maintain effective relationships, as well as impaired impulse control, characterized by unprovoked irritability with periods of violence. Nonetheless, in the opinion of the examiner, the Veteran's level of occupational impairment was best summarized as consisting of occupational and social impairment, with occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The pertinent diagnosis noted was posttraumatic stress disorder, with a Global Assessment of Functioning Score of 65. In the opinion of the examiner, while the Veteran described many symptoms associated with a diagnosis of posttraumatic stress disorder, and had carried that diagnosis by history, it was important to note that he described himself as an alcoholic who drank for many years of his life, never received treatment for his alcohol use, and only stopped in 1983 following a motor vehicle accident where, by his own account, he was drunk, fell asleep at the wheel, and his truck caught on fire. The Veteran additionally admitted to drug use both before going to Vietnam and after his return. Significantly, in the opinion of the examiner, it was difficult to know how many of the Veteran's symptoms might also have been caused by his alcoholism and drug use. In that regard, by the Veteran's own admission, his alcoholism had led to many aggressive fighting incidents. Nonetheless, according to the examiner, over and above the symptoms which the Veteran described, it was important to note that he was also quite functional on a daily basis. When asked about his hobbies, the Veteran indicated that he liked to hunt and fish, had recently joined the fire department as part of the fire police, and went out to restaurants with his wife. Further noted was that the Veteran traveled "a fair bit," having gone on Alaskan and Caribbean cruises, and planned a flight to visit his son in Minnesota in the near future. Significantly, when questioned, the Veteran indicated that he was encouraged to ask for an increase in his service connection by people who said he should get more because of his symptoms. However, according to the examiner, while the Veteran described many symptoms of posttraumatic stress disorder throughout the years, there was no reason to suspect that an increase was necessarily in order given his financial status, and ability to function "quite well" on a day-to-day basis. Pursuant to applicable law and regulation, a 30 percent evaluation is warranted for service-connected posttraumatic stress disorder where there is evidence of 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, and/or mild memory loss (such as forgetting names, directions, or recent events). A 50 percent evaluation, under those same laws and regulations, requires demonstrated evidence of 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; and/or difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is evidence of 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 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/or an inability to establish and maintain effective relationships. Finally, a 100 percent evaluation is warranted where there is demonstrated evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communications; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting oneself or others; intermittent inability to perform the activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, one's own occupation, or one's own name. 38 C.F.R. § 4.130 and Part 4, Diagnostic Code 9411 (2012). The Board notes that, although the Rating Schedule lists specific symptoms that are indicative of total impairment, the United States Court of Appeals for Veterans Claims (Court) has held that the symptoms listed in the Rating Schedule are only examples, and that evidence of those specific symptoms is not required to show that the Veteran is totally disabled. In rating a mental disability, VA is required to consider all symptoms which affect the Veteran's social and occupational functioning, and not limit consideration to those symptoms listed in the Rating Schedule. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In other words, the primary consideration is whether the manifestations of the service-connected psychiatric disorder result in total social and occupational impairment, regardless of whether the Veteran demonstrates those symptoms listed in the Rating Schedule. When evaluating the level of disability from a mental disorder, the rating agency must 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." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. 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 social 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 reflects 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 jobs). While the Rating Schedule does indicate that the rating agency must be familiar with the Diagnostic and Statistical Manual of Mental Disorders, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2012). Rather, GAF scores are one factor to be considered in conjunction with all other pertinent evidence of record. In light of the evidence, it is clear that, for the period prior to September 5, 2008, no more than a 30 percent evaluation was warranted for the Veteran's posttraumatic stress disorder. Significantly, at no time during that period did the Veteran exhibit symptomatology consistent with a 50 percent evaluation, such as circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; or impaired judgment. Rather for the period in question, the Veteran was most often described as alert and for the most part oriented, with good hygiene, and intact memory and judgment. In fact, as recently as June 2005, it was noted that the Veteran was able to conduct all activities of daily living without difficulty, and that he had a good relationship with his immediate family members. While on VA examination at that time, the Veteran's mood was somewhat dysphoric; his speech was unremarkable in all respects, as well as relevant, coherent and goal-directed. Moreover, the Veteran did not appear to suffer from either visual or auditory hallucinations, or any other form of perceptual or cognitive distortion. Not until the time of a subsequent VA psychological evaluation on September 5, 2008 was there evidence of dysfluent, (which is to say, circumstantial, circumlocutory, or stereotyped) speech commensurate with a 50 percent evaluation. Significantly, at that time, it was noted by the examiner that the Veteran's dysfluent speech was representative of a "change in the status of his functioning from when he was last seen." Moreover, that same examiner, for the first time, indicated that, while the Veteran's remote memory appeared to be intact, his short term and immediate memory now appeared to be impaired. Once again, according to the examiner, this represented a change from when the Veteran was previously seen, though the "authenticity" of his capacity could not be assessed. This was felt to be the case given that, throughout the course of the evaluation, the Veteran appeared to be "overreporting" his symptoms. In any case, at no time prior to August 9, 2012, the date of a subsequent VA psychological examination, was there evidence of symptomatology arguably consistent with a 70 percent evaluation. The Board notes that, at the time of that VA psychological evaluation in August 2012, the Veteran described many symptoms associated with posttraumatic stress disorder, including a tendency to isolate and not make friends, as well as hypervigilance, a startle reflex, and a tendency to become angry and somewhat hostile when challenged. Nonetheless, according to the examiner, the Veteran functioned "quite well" on a day-to-day basis. The Veteran's posttraumatic stress disorder symptomatology was described as producing occupational and social impairment with only occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. While at the time of examination, there was some evidence of suspiciousness, as well as chronic sleep impairment, impaired judgment, and impaired impulse control, there was no evidence of the gross impairment in thought processes or communication, disorientation to time or place, or persistent delusions/hallucinations representative of a total (100 percent) evaluation. In fact, according to the examiner, while the Veteran described many symptoms of posttraumatic stress disorder, there was "no reason" to suspect that an increase was necessarily in order given the Veteran's current financial status and ability to function "quite well" on a day-to-day basis. Based on the aforementioned, the Board is of the opinion that the respective 30, 50, and 70 percent evaluations assigned for the periods in question are appropriate, and that increased evaluations are not warranted. Accordingly, the Veteran's claim for increased benefits must be denied. The Board has also considered whether the Veteran's disability picture presents an exceptional or unusual disability picture sufficient to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular evaluation is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996). However, in the case at hand, there are no exceptional or unusual factors with regard to the Veteran's posttraumatic stress disorder. 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 Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ["the Rating Schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."] Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for additional or more severe symptoms than currently shown by the evidence. Accordingly, the Veteran's disability picture is adequately contemplated by the Rating Schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, inasmuch as a preponderance of the evidence is against the Veteran's claim for increase, that doctrine is not applicable in the present appeal. See 38 U.S.C.A. § 5107(b) (West 2002); see also Ortiz v. Principi, 274 F.3d, 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER An increased rating for posttraumatic stress disorder, initially evaluated as 30 percent disabling prior to September 5, 2008, 50 percent disabling during the period from September 5, 2008 to August 9, 2012, and as 70 percent disabling thereafter, is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs