Citation Nr: 1314407 Decision Date: 05/01/13 Archive Date: 05/15/13 DOCKET NO. 08-33 818A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUE Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served in the Recognized Guerillas from September 1943 to September 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. In June 2010, the Veteran and his son testified at the RO before a Decision Review Officer (DRO). A transcript of that hearing has been associated with the claims file. The case was previously remanded by the Board in December 2011 for further evidentiary development. As will be discussed below, the Board's prior remand instructions have been substantially complied with, and thus, the Board may proceed with appellate adjudication of the Veteran's claim. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). In June 2012, the RO denied the Veteran's claim of entitlement to a total disability rating based upon individual unemployability (TDIU). This claim considered service-connected disabilities, including PTSD. See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009) (holding that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities; if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted). However, the Veteran did not appeal this issue, and has not sought to pursue the claim, nor has any new evidence raised the issue of entitlement to TDIU since it was last denied. As such, the Board finds that a claim of entitlement to a TDIU is not reasonably raised at this time. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The Veteran's PTSD is manifested by depressed mood, anxiety, anger, irritability, nightmares, intrusive recollections, chronic sleep impairment, flashbacks, physical reaction to trauma-related stimuli, hypervigilance, concentration and attention disturbance, exaggerated startle response, avoidance behaviors, and emotional numbness. Objectively, the Veteran was appropriately dressed and groomed, alert, fully-oriented, cooperative, attentive, and pleasant. He exhibited variable mood; blunted, constricted or congruent affect; fair insight and judgment; good impulse control; spontaneous and coherent speech; and linear thought process. No active suicidal or homicidal ideation, hallucinations, delusions, psychosis, violence problems, or inappropriate behaviors were shown. CONCLUSION OF LAW The criteria for an initial rating greater than 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has met all statutory and regulatory notice and duty to assist provisions under the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This 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). The Veteran's claim concerning the proper disability rating to be assigned to his service-connected PTSD at issue arise from his disagreement with the initial disability rating assigned to this condition following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice as to these claims is needed under VCAA. The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, as well as his post service medical records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA examinations were conducted in May 2008, August 2011 and February 2012. 38 C.F.R. § 3.159(c)(4). Each examiner conducted an interview of the Veteran, who was accompanied by his family, and mental status examination, recorded clinical findings, and documented the Veteran's subjective complaints. As these examinations included sufficient detail as to the current severity of his service-connected disability, the Board concludes that these examinations are adequate for evaluation purposes. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In particular, the Veteran's claim was remanded in December 2011 to provide the Veteran an updated VA examination to ascertain the current severity of his PTSD. This was accomplished in the February 2012. Therefore, the Board finds that there has been substantial compliance with its December 2011 remand. See Dyment, 13 Vet. App. at 146-47; Stegall, 11 Vet. App. at 272. Although the VA PTSD examinations obtained in August 2011 and February 2012 did not indicate that the Veteran's claims file was reviewed, the Board finds that this does not constitute a prejudicial error. Here, an increase in the disability ratings is at issue and the present level of the Veteran's service-connected disability is of primary concern. As it would not change the objective and dispositive findings made during the VA examinations, review of the claims file was not required. See Snuffer v. Gober, 10 Vet. App. 400, 403-04 (1997). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). 38 C.F.R. § 3.103(c)(2) (2012) requires that the Decision Review Officer (DRO) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the DRO hearing, the DRO fully explained the issues. The Veteran was assisted at the hearing by an accredited representative from the Disabled American Veterans. The representative and the DRO asked questions to ascertain the current state of the Veteran's service-connected disability, and the hearing focused on the evidence necessary to substantiate the Veteran's claim of increased rating for PTSD. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or the representative. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that the DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). Evaluation of a service-connected disability requires a review of a veteran's medical history with regard to that disorder. However, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where a veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. Service connection for PTSD was granted in a June 2008 rating decision, and a 30 percent initial disability rating was assigned effective September 25, 2007 under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. Subsequently, in a July 2010 rating decision, the RO increased the initial rating for PTSD to 70 percent, effective September 25, 2007. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The Veteran's service-connected PTSD is evaluated as 70 percent disabling under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411. Ratings are assigned according to the degree of occupational and social impairment resulting from manifestations of the disability at issue. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the provisions for rating psychiatric disorders, a 70 percent rating is warranted when there is 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.). A 100 percent rating is warranted when there is 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board notes that the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, 16 Vet. App. 436. Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on 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). While not determinative, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). According to DSM-IV, a GAF score ranging from 31-40 reflects 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; child frequently beats up other children, is defiant at home, and is failing at school). A GAF score of 41-50 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 a job). 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 peers or co-workers). A GAF score of 61-70 denotes some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 71-80 indicates that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). In a September 2007 VA mental health initial assessment note, the Veteran relayed a history of military service during the World War II. He reported PTSD symptoms, including intrusive thoughts, nightmares, flashbacks, physical reactions to reminders, avoidance of thinking or talking about trauma, avoidance of situations and activities that were reminders, loss of interest in pleasurable activities, emotional numbness, foreshortened sense of future, sleep and concentration problems, guardedness, and exaggerated startle related to combat trauma. His son reported that his father folded his hands together tightly which signaled the son that he was reexperiencing the trauma and that it could go on for hours. The Veteran also reported feeling guilty, depression including discontinuance of pleasurable activities, feeling life is empty, dysphoria, feeling helpless, worthless, and hopeless, isolating, and lack of energy. He denied any history of suicidal acts, violence, or legal problems. Concerning psychosocial history, the Veteran reported that he was married and had 6 children. He had a close relationship with his family. However, although he came to the Filipino Veterans center, he did not spend much time with the other veterans. On mental status examination, the Veteran had appropriate grooming; cooperative behavior, normal and spontaneous speech, linear thought process, and thought content with no evidence of current suicidal or homicidal ideation, auditory or visual hallucinations, or delusions. His affect was appropriate to content and his mood was depressed. He was alert and fully oriented and had fair insight and judgment. Assessment of violence risk was low with no history or current homicidal ideation. The initial DSM-IV diagnoses were PTSD and depressive disorder, not otherwise specified, on Axis I, and a GAF score of 45 was listed. VA psychology progress notes, dated October 2007 to June 2011, indicate that objectively, the Veteran exhibited appropriate grooming, and cooperative behavior, and normal and spontaneous speech, linear thought process, and thought content with no evidence of current suicidal or homicidal ideation, auditory or visual hallucination, or delusions. His affect was appropriate to content and mood was depressed. He was alert and fully oriented, and his insight/judgment was fair. The assessments were PTSD and depressive disorder, not otherwise specified, and a GAF score of 45 was noted. The Veteran underwent a VA PTSD examination in May 2008. After reviewing the claims file, the VA examiner noted that the Veteran had been treated for PTSD since September 2007. There was no history of hospitalizations for a mental disorder and the Veteran did not take psychiatric medication. With regard to family and social relationships, he had been married for nearly 55 years and had 6 children. The Veteran reported intense anger in what he described as otherwise good relationships with wife and children. Regarding his social interaction with friends and other people, he stated "sometimes they misunderstand me, but not always." He mostly stayed at home or sometimes attended an adult senior center. He denied a history of suicide attempts or violence/assaultiveness. His current psychosocial functional status was summarized as "fair to good interpersonal relationships that were sometimes disrupted by his tendency to have intense anger (associated with PTSD)." On mental status examination, the Veteran was clean, appropriately dressed and fully oriented. He exhibited unremarkable psychomotor activity; spontaneous, clear, and coherent speech; cooperative and attentive attitude; appropriate, constricted, and blunted affect; anxious, depressed, and fearful mood; attention disturbance; unremarkable thought process; and unremarkable thought content with no delusions; above average intelligence; good impulse control; and normal memory. He understood the outcome of his behaviors and that he had a problem. No hallucinations, inappropriate behaviors, obsessive/ritualistic behavior, panic attacks, homicidal or suicidal thoughts, or episodes of violence were shown. He was not able to maintain minimum personal hygiene and his son was his caretaker. The Veteran was capable for managing financial affairs. The Veteran retired in 1993. The diagnosis was chronic PTSD with depressed mood, and a GAF score of 50 over the previous two years. It was noted that the Veteran had serious PTSD symptoms with associated depressed mood and anger and triggered by "loud noises, particularly gunshots and helicopters." The examiner noted that the Veteran's functional status was fair and there was no total occupational and social impairment due to PTSD signs and symptoms resulting in deficiencies in the areas, such as judgment, thinking, family relations, and mood. The examiner further noted that there was reduced reliability and productivity due to PTSD symptoms. In a VA psychiatry progress note dated September 2008, the Veteran had nightmares being in the front line and being fired at. He had nightmares 2 to 3 times per month, which had been happening for many years now, and had learned to ignore it. The assessments were insomnia and history of PTSD. In VA psychiatry progress notes dated February 2009, the Veteran continued to have sleep problem. He slept only for 2 to 3 hours per night. When awake, he thought about the past and got preoccupied with war-time experience. On mental status examination, the Veteran was stable with no overt psychosis. The assessment was PTSD. In a VA psychiatry progress note dated December 2009, the Veteran complained of poor sleep at night and vivid dreams of war-time experience. On mental status examination, the Veteran was alert and fully oriented. He showed coherent speech and mildly dysphoric mood, but no psychosis. The assessment was PTSD. In a VA psychiatry progress note dated July 2010, the Veteran reported doing fine. He continued to have problem with sleep and he slept only 3 to 4 hours at night but took naps during the day. On mental status examination, the Veteran was alert, fully oriented, well dressed and groomed, and friendly. He showed coherent speech and euthymic mood. No psychosis, or suicidal or homicidal ideation was shown. The assessment was PTSD. At his June 2010 RO hearing, the Veteran testified that loud noise caused great deal of emotion distress. He stated that he had not yet reached the point of having suicidal or homicidal ideation or paranoia, but he had suicidal or homicidal thoughts before. He also reported symptoms of sleep disturbance, intrusive recollection about his combat experience, ritualistic behaviors such as checking behind him all the time, and hallucination in that he felt as if he was bowling or flying. His son who was present at the hearing testified that the Veteran had been willing to attend social gatherings on some occasions. In a VA psychiatry progress note dated November 2010, the Veteran reported doing fine. He continued to have problem with sleep and he slept only 3 to 4 hours at night but took naps during the day. On mental status examination, the Veteran showed euthymic mood. No psychosis or suicidal or homicidal ideation was shown. The assessment was PTSD. In VA psychiatry progress notes dated June and July 2011, the Veteran complained of insomnia and nightmares. On mental status examination, the Veteran showed mildly anxious mood, but no psychosis or suicidal or homicidal ideation. The assessment was PTSD. VA psychology progress notes, dated June 2011 to May 2012, indicate that objectively, the Veteran exhibited appropriate grooming, cooperative behavior, normal and spontaneous speech, linear thought process, and thought content with no evidence of current suicidal or homicidal ideation, auditory or visual hallucination, or delusions. His affect was appropriate to content and mood was euthymic or depressed. He was alert and fully oriented, and his insight/judgment was fair. The assessments were PTSD and depressive disorder, not otherwise specified, and a GAF score of 50 was noted. A VA examination was conducted in August 2011. The examination report stated that that the Veteran had attended a weekly PTSD therapy group and individual psychotherapy and that while he enjoyed the group experience, his PTSD symptoms had deteriorated over the past three years, despite good adherence to group and individual psychotherapy and medication compliance. The examiner noted the Veteran's memory impairments, which were not currently being treated, and a history of depression. Based on interview of the Veteran and collateral reports from his wife and eldest son who were present for the interview, the examiner reported that the Veteran's overall medical and mental health had deteriorated significantly since he was first diagnosed with PTSD. With regard to family and social relationships, the Veteran had close relationships with his wife of nearly 57 years and all six of his children. However, his wife and eldest son reported that the Veteran had become increasingly more irritable over the past few years. The Veteran had few friends other than some of the members of his PTSD therapy group and he was able to maintain close relationships with his wife and children because they were willing to tolerate his frequent angry outbursts, which had increased over the past few years. The Veteran only leisure pursuit was watching sporting events on television as multiple medical problems made it difficult for him to pursue other leisure activities. The Veteran had no history of suicide attempts or violence/assaultiveness. He slept only about two or three hours each night and the frequency and severity of his nightmares had increased. His wife no longer slept in the same bedroom even though they were a loving and devoted couple. The Veteran continued to have unwanted intrusive recollections of his combat experiences. His startle response was exaggerated and flashbacks were triggered by helicopter sounds and loud noises. On mental status examination, the Veteran was clean, neatly groomed, and appropriately dressed. He showed fatigued psychomotor activity; impoverished and coherent speech; cooperative, friendly, relaxed, and attentive attitude; blunted affect; dysphoric mood; intact attention and orientation; unremarkable thought process and thought content; no delusions; average intelligence; and good impulse control. He understood the outcome of his behaviors and that he had a problem. No hallucinations, inappropriate behaviors, obsessive/ritualistic behavior, panic attacks, homicidal or suicidal thoughts, or episodes of violence were shown. He was able to maintain minimum personal hygiene and there was no problem with activities of daily living. However, multiple medical problems had impaired the Veteran's ability to perform several activities of daily living and his memory was impaired. The Veteran was not capable for managing financial affairs and his daughter assisted him and his wife with money management. The Veteran's immediate family maintained close relationships and his wife and children provided assistance readily; family relationships were strong and loving. The diagnoses were PTSD and cognitive disorder, not otherwise specified. A GAF score of 40 was assigned. The examiner noted that the Veteran's PTSD symptoms had deteriorated since his last exam but his memory problems did not appear to be related to nor accounted for his PTSD symptoms. In particular, there had been significant deterioration of the areas of routine responsibilities of self-care, family role functioning, physical health, social/interpersonal relationships, and recreation/leisure pursuits. The examiner commented that although the Veteran was retired and consequently, his PTSD symptoms did not interfere with occupational functioning, his symptoms would likely interfere with occupational functioning if the Veteran was still employed. His symptoms have impaired social functioning both within and outside of his immediate family. Irritability and low frustration tolerance had contributed to temper control problems which had strained family relationships and which had increased argumentativeness within and outside of the family. In a December 2011 VA psychiatry progress note, the Veteran was doing fairly well. He reported that he still had nightmares of being in war. He also reported having dreams of being in a party and enjoying himself or being in romantic company of his wife. He attended PTSD therapy regularly. On mental status examination, the Veteran was alert, oriented, appropriately dressed and groomed, friendly, and cooperative. He showed coherent speech and mildly anxious mood. No psychosis or suicidal or homicidal ideation was shown. The assessment was PTSD. The Veteran underwent a VA PTSD examination in February 2012. The VA examiner noted diagnoses of PTSD and cognitive disorder, not otherwise specified, on Axis I, and stated that it was possible to differentiate symptoms attributable to each diagnosis. Specifically, he attributed symptoms of persistent intrusive recollections, avoidance behaviors, and hyperarousal symptoms to PTSD. However, symptoms of diminished cognitive abilities in areas of registration memory and short-term recall and capacity to access long-term memory, as well as diminished attention and concentration abilities were attributed to his cognitive disorder. The examiner noted that the Veteran's level of occupational and social impairment with regards to his mental diagnoses was best summarized as occupational and social impairment with reduced reliability and productivity. The Veteran reported currently living with his wife of 57 years. They had 6 grown children and 11 grandchildren. He was currently retired from his job as a security guard since 1993. He reported that he got along well with his wife. They mostly stayed at home but occasionally went out to a mall, church, or a park with their children. They went to church every Sunday and shopping on Saturdays. He related that he was comfortable in church or going out with his children. His son stated that the Veteran seemed to enjoy going out. His activities at home included sleeping, eating, watching television or listening to music. He reported trouble sleeping and daydreaming about the past. He was very sensitive to loud sounds, especially when he heard sirens or loud trucks going by. His son clarified that the Veteran "gets nervous." He stopped whatever he was doing when he heard these sounds and seemed to notice and remember his time in combat. The Veteran stated, and his son concurred, that they have noted no changes in social or familial circumstances since the Veteran was last evaluated in August 2011. The Veteran was seen by Dr. Goguen and had been attending a weekly PTSD support group since 2007. He enjoyed the group, and related that "I learned a lot." However, he reported that his sleep problem was worse and he took medications as needed. He still thought about his war experiences with the same frequency as before he started attending the group. He also reported no change in the degree or frequency of hypervigilance. He had no legal problems. He and his son reported no changes in his daily behavior since August 2011. In making the PTSD diagnosis, the examiner found symptoms of recurrent and distressing recollections of the traumatic event; recurrent distressing dreams of the event; acting or feeling as if the traumatic event were recurring; including a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes; physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; efforts to avoid thoughts, feelings or conversations associated with the trauma; inability to recall an important aspect of the trauma; difficulty falling or staying asleep; hypervigilance; and exaggerated startle response. The examiner concluded that these PTSD symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner also noted that the following symptoms applied to the Veteran's diagnoses: depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks; and difficulty in adapting to stressful circumstances, including work or a work-like setting. Based on a thorough review of all of the evidence of record, as outlined above, the Board finds that the Veteran's total disability picture most closely approximates the criteria for a 70 percent disability rating. 38 C.F.R. § 4.7 (2012). In reaching this determination, the Board finds it significant that the VA examiners and physicians, who conducted a comprehensive psychiatric assessment of the Veteran, diagnosed PTSD, and estimated that his GAF scores were 40 to 50, which, as discussed above, are indicative of symptoms somewhere in the range from impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood and serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social or occupational functioning, such as no friends, unable to keep a job. Furthermore, the Veteran's symptomatology of depressed mood, anxiety, anger, irritability, nightmares, intrusive recollections, chronic sleep impairment, flashbacks, physical reaction to trauma-related stimuli, hypervigilance, concentration and attention disturbance, exaggerated startle response, avoidance behaviors, and emotional numbness, are compatible with a GAF score in the 40 or 50s. In short, the Board finds that the Veteran's PTSD results in significant impairment in social and occupational functioning, with deficiencies in most areas, such as work, family relations, judgment, or mood, due to such symptoms as depressed mood, anxiety, anger, irritability, nightmares, intrusive recollections, chronic sleep impairment, flashbacks, physical reaction to trauma-related stimuli, hypervigilance, concentration and attention disturbance, exaggerated startle response, avoidance behaviors, and emotional numbness. However, the Veteran's total disability picture does not rise to the severity required for a 100 percent rating. In this regard, the Board finds that total social and occupational impairment has not been shown in this case. Throughout the record, the Veteran has shown to have maintained a close relationship with his family and occasional social interaction with other people. He has been married to his wife for over 55 years and his children and wife have been a great support system. To that effect, at the May 2008 VA examination that the Veteran described good relationships with wife and children other than his anger problem. Regarding his social interaction with friends and other people, he stated that "sometimes they misunderstand me, but not always." Further, at the June 2010 RO hearing, his son indicated that the Veteran would occasionally attend social gatherings. At the August 2011 VA examination, the Veteran's wife and his son reported that the Veteran had become increasingly more irritable over the past few years; he had few friends other than some of the members of his PTSD group. The examiner opined that the Veteran's symptoms would likely interfere with occupational functioning if the Veteran was employed because of his irritability and low frustration tolerance. However, despite the increased argumentativeness within and outside his family, the Veteran was able to maintain close relationships with his wife and children. At the February 2012 VA examination, the Veteran reported that he got along with his wife and they occasionally went to shopping, church or a park with their children. He stated that he was comfortable in church or going out with his children. His son also stated that the Veteran seemed to enjoy going out. Accordingly, while the Veteran has shown significant difficulty in social relationships, he has also demonstrated that he is able to establish and maintain some social relationships, including his over 55 year long marriage to his wife and good relationships with his children and some friends. The Board finds significant the May 2008 VA examiner's characterization of the Veteran's psychosocial functional status as "fair to good interpersonal relationships," that were sometimes disturbed by his tendency to have intense anger associated with PTSD. Further, the same VA examiner specifically found that there was no total occupational and social impairment due to PTSD signs and symptoms resulting in deficiencies in the areas, such as judgment, thinking, family relations, and mood." Rather, both the May 2008 and February 2012 VA examiners opined that the Veteran's level of social and occupational functioning was best summarized as reduced reliability and productivity, which is consistent with the other medical evidence of record as well as the lay testimony from the Veteran and his family. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Nor does the credible lay and medical evidence demonstrate gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, or disorientation to time and place. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran has shown be fully oriented with coherent speech and linear thought process and his behaviors were noted as appropriate at all of his VA examinations and VA treatment sessions. The record is devoid of evidence indicating that the Veteran has had any episode of violence or active aggression. The VA examination reports consistently indicate no history any violence, assaultiveness, or legal problems. Throughout the record, the Veteran was appropriately dressed and groomed, alert, fully-oriented, cooperative, attentive and pleasant. On mental examinations, he exhibited variable mood; blunted, constricted or congruent affect; fair insight and judgment; good impulse control; spontaneous and coherent speech; and linear thought process. No active suicidal or homicidal ideation, hallucinations, delusions, psychosis, violence problems, or inappropriate behaviors were shown. Concerning this, at the June 2010 RO hearing, the Veteran admitted that he had suicidal and homicidal thoughts before but he stated that he had not yet reached the point of having suicidal or homicidal ideation or paranoia. Further, over the entire rating period, the Veteran denied current suicidal or homicidal ideation. Further, the Veteran reported hallucinations in a sense that he felt like bowling or flying. However, it appears that the Veteran was referring to his physical reaction to trauma-related reminders, as he has otherwise denied any auditory or visual hallucinations at all times. Thus, the Board finds no persistent hallucinations or delusions. The Veteran's mild memory loss and intermittent inability to perform activities of daily living have been shown. Specifically, the May 2008 VA examiner report noted that the Veteran was not able to maintain minimum personal hygiene and his son was his caretaker. The August 2011 VA examiner notes that multiple medical problems impaired the Veteran's ability to perform several daily activities of daily living and his daughter and wife assisted him in financial affairs. More recently, by a September 2012 rating decision, the Veteran was found incompetent for VA purposes. However, the August 2011 VA examiner noted that the Veteran's memory problems was not related to nor accounted for his PTSD symptoms. Concerning this, the Board notes that it is precluded from differentiating between the symptomology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). In this case, however, the February 2012 VA examiner have clearly distinguished the symptoms due to PTSD from the symptoms due to the Veteran's cognitive disorder. The February 2012 VA examiner specifically attributed the Veteran's symptoms of diminished cognitive abilities including memory loss, diminished attention and concentration abilities to his cognitive disorder diagnosis. Further, while the Board recognizes that memory loss and intermittent inability to perform activities of daily living are listed as an example of symptoms warranting a 100 percent evaluation, as discussed above, the symptoms listed in the 38 C.F.R. § 4.130 are intended to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan, 16 Vet. App. at 442. However, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code, but it must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The February 2012 VA examiner indicated her opinion that the Veteran's PTSD symptoms produced occupational and social impairment with reduced reliability and productivity, but did not produce occupational and social impairment with deficiencies in most areas such as work, school family relations, judgment, thinking, or mood, and did not produce total occupational and social impairment. The evidence does not support a finding of total occupational and social impairment that is the criteria for a 100 percent rating for PTSD. Accordingly, considering evidence in totality, the Board finds that the Veteran's disability picture more nearly approximates the criteria for the 70 percent disability rating, and therefore the 70 percent rating is the appropriate rating in this case. 38 C.F.R. § 4.7. The issue has been reviewed with consideration of whether staged ratings would be warranted. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, there is no evidence of record that would warrant a rating in excess of 70 percent for his PTSD during the rating period on appeal. See Fenderson, 12 Vet. App. at 126. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a 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 and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321(b) (1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The schedular rating in this case is adequate. The diagnostic criteria contemplate and adequately describe the symptomatology of the Veteran's service-connected PTSD. See Thun, 22 Vet. App. at 115. The Veteran's PTSD is evaluated by the rating criteria which specifically contemplate the level of occupational and social impairment caused by this disability. See 38 C.F.R. § 4.130, Diagnostic Code 9411. When comparing the Veteran's psychiatric symptoms and social and occupational impairment with the schedular criteria, the Board finds that his symptoms are congruent with the disability picture represented by the currently assigned 70 percent rating and he does not have symptoms associated with this disability that have been unaccounted for by the currently assigned schedular rating. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Accordingly, a comparison of the Veteran's symptoms and functional impairments resulting from PTSD with the pertinent schedular criteria does not show that his service-connected PTSD presents "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Consequently, the Board finds that the available schedular rating is adequate to rate the Veteran's PTSD. Based on this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). As such, referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. ORDER Entitlement to an initial rating in excess of 70 percent for PTSD is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs