Citation Nr: 1315084 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 10-20 989 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from April 1969 to April 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. During the course of the appeal, the Veteran was awarded an increased evaluation of 50 percent. See September 2012 rating decision. Applicable law mandates that when a Veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). As the Veteran has not expressed satisfaction with the assigned 50 percent rating, the Board concludes that the issue remains on appeal. The Board notes that the Veteran requested a Travel Board hearing before a Veterans Law Judge, but withdrew his request for a hearing through written correspondence, dated in August 2011. The Veteran having withdrawn his hearing request, the Board will proceed to adjudicate the case based on the evidence of record. See 38 C.F.R. § 20.704 (e) (2012). The case was remanded in March 2012 and November 2012 to obtain additional treatment records and afford the Veteran a new VA examination. Review of the record indicates substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that the claims file reflects that the Veteran was previously represented by the North Carolina Division of Veterans Affairs (NCDVA) (as reflected in an August 2005 VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative). In October 2008, VA received notification from NCDVA withdrawing from appointment as accredited representative. In October 2011, the Veteran indicated his desire to revoke any previously assigned power of attorney (POA), and the Board recognizes the Veteran as proceeding pro se. Please note 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 evidence does not demonstrate that the PTSD results 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); or spatial disorientation. CONCLUSION OF LAW The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and 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. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant was must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing his or her entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of the specific diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was notified in a letter dated in April 2009 regarding the type of evidence necessary to establish his claim. He was instructed that to show entitlement to an increased evaluation for his service-connected disability, the evidence must show that the disability has gotten worse. He was advised of what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. Additionally, the letter notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In addition, the April 2009 letter as well as an August 2009 letter informed the Veteran that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Regarding VA's duty to assist, the RO obtained the Veteran's post-service medical records and also secured examinations in furtherance of his claim. Pertinent VA examinations were obtained in April 2009 and May 2012. 38 C.F.R. § 3.159(c)(4). The VA examinations obtained in this case are sufficient, as the examiners conducted complete examinations, recorded all findings considered relevant under the applicable diagnostic code, and considered the full history of the disability. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issue adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). VA has no duty to inform or assist that was unmet. The Veteran has not identified any additional pertinent medical records that have not been obtained and associated with the claims folder. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7. Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The United States Court of Appeals for Veterans Claims (Court) has held that staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App 505 (2007). As discussed in detail below, the Board concludes that a staged rating is not warranted. The Veteran contends that he is entitled to a rating in excess of 50 percent for the service-connected PTSD due to the severity of his symptomatology. This service-connected disability is rated as 50 percent disabling under 38 C.F.R. § 4.130, DC 9411, which evaluates impairment from PTSD. Specifically, pursuant to DC 9411, a 50 percent evaluation is warranted if the evidence establishes there is 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. 38 C.F.R. § 4.130, DC 9411 (2012). A 70 percent evaluation is warranted if the evidence establishes 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted if the evidence establishes 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 oneself 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. Id. The list of symptoms in the rating formula is not intended to constitute an exhaustive list, but rather shows examples of the types and degrees of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). 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(b). The Global Assessment of Functioning (GAF) is 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 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). A GAF score of 51 to 60 is indicative of 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 co-workers). A GAF score of 41 to 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31 to 40 is indicative of 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 younger children, is defiant at home, and is failing at school). Based on the evidence of record, the Board concludes that a rating in excess of 50 percent is not warranted at any time during the pendency of this appeal. Throughout this appeal, the pertinent evidence record has not shown 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; or spatial disorientation. Although the evidence does show symptoms such as neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and the inability to establish and maintain effective relationships, the totality of the symptomatology shown throughout this appeal does not equate to occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. A private treatment record from H.J., M.D. in February 2009 fails to show occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. The Veteran reported thoughts of suicide on multiple occasions, especially in the past and that suicide ideation had tempered down lately. He continued to have flashbacks and nightmares. The Veteran reported that he did not have any friends or social activities. He maintained his current job as a custodian in the school system since he was hired in 2002. He reported that the children got on his nerve easily, but he had developed symptoms to run away from the situation and walk outside. He continued to be very paranoid in unfamiliar situations, scan his surroundings, did not like surprises, and had a heightened level of anxiety and restlessness and easy irritability. Examination revealed him to be slightly disheveled. He was able to maintain good eye contact and was able to relate very well. Thought processes were within normal limits, goal directed and logical. He had some problem recalling details about the traumatic event in service. He had the ability to give clear account as to what happened. He denied any auditory or visual hallucinations and suicidal ideation or homicidal ideation. There was no evidence to any psychosis or delusions. His mood was depressed and anxious; affect was congruent to mood. The Veteran was alert and oriented. He was able to register and recall; remote and recent memory were intact; attention and concentration were slightly affected; and he had good insight and judgment. His GAF score was 40. This evaluation fails to show that the Veteran has occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. The Veteran was shown to be gainfully employed in the same position since he was hired in 2002, showing that he did not have deficiencies in employment. As the Veteran was shown to have good judgment, the evidence does not suggest occupational and social impairment in such area as judgment. Since his concentration and attention were slightly affected, this evaluation does indicate that he did have deficiencies in thinking, although his thought processes were within normal limits. Although the Veteran indicated having suicidal ideation in the past, he denied such symptom at the time of the examination. Despite the Veteran having some problems with children, he developed symptoms to deal with such problems, indicating that he did not have difficulty in adapting to stressful circumstances. As the Veteran denied having friends, this record does indicate the inability to establish and maintain effective relationships. Additionally, it shows that he was disheveled, suggesting neglect of personal appearance and hygiene. However, the overall symptoms noted on examination fail to show that he meets the criteria for a 70 percent evaluation. The results of an April 2009 VA examination also fails to show that the Veteran has occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. He continued to be employed full-time as a custodian and reported working regularly. He dressed and fed himself and attended to his own toilet needs. The Veteran lived with his wife and did chores around the house. He had some friends and went to church. He had five children and was pretty close to his children. The Veteran did have some recreational and leisure pursuits. Examination revealed that he was alert, cooperative, appropriately dressed, soft-spoke and polite. He answered questions and volunteered little information. There were no loosened associations or flight of ideas and no bizarre motor movements or tics. His mood was a bit tense, but cooperative and friendly; affect was appropriate. He stated that he had nightmares and some intrusive thoughts. He had no homicidal or suicidal ideation; no impairment of thought processes or communication; and no delusions, hallucinations, ideas of reference or suspiciousness. He was oriented times three; remote and recent memory appeared to be adequate; and insight and judgment appeared to be adequate. His GAF score was 54. The examiner commented that the Veteran had moderate and persistent symptoms of PTSD with no remissions. He was working full-time on a regular basis. He was not irritable; got withdrawn at times; and had some sadness. He had a few friends, did go to church and had some interests. The examiner opined that the Veteran's symptoms resulted in some impairment of employment and social functioning. As with the February 2009 private evaluation, the April 2009 VA examination also fails to show occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. After examining the Veteran, it was the examiner's opinion that the Veteran's symptoms resulted in some impairment of employment and social functioning; the examiner further opined that the Veteran's PTSD symptoms were moderate, consistent with the currently assigned 50 percent rating. The Veteran was shown to attend church, had friends and also was close with his children. The fact that the Veteran remained married and was close with his children suggests that he did not have deficiencies in family relations. He also did not have deficiencies in work as he continued to be employed full-time. Furthermore, the Veteran's judgment was opined to be adequate, indicative that he was not deficient in judgment. Although his mood was a bit tense, suggesting deficiency in that area, since no impairment of thought processes or communication, and no delusions, hallucinations, ideas of reference or suspiciousness were shown, the Board concludes that the Veteran did not have deficiencies in thinking. The Veteran's tense mood and report of some sadness suggest deficiencies in mood. However, the actual symptoms shown on this examination are not those contemplated for by a 70 percent rating. Consequently, the results of this examination fail to show that the Veteran meets the criteria for a 70 percent rating. Pertinent treatment records from Dr. H.J. dated through April 2012 also does not show occupational and social impairment with deficiencies in most areas. As with the February 2009 evaluation from Dr. H.J., these records show that the Veteran continued to be disheveled, showing a neglect of personal appearance and hygiene, one of the symptoms contemplated for by a 70 percent rating. The records show that the Veteran was repeatedly stressed; however, they also indicate that the Veteran's wife had multiple medical problems causing him stress. See, e.g., April 2011 record. The records also reveal that the Veteran had very little socialization and stayed away from people. See, e.g., April 2010, April 2011 treatment records. An August 2011 record indicates that the Veteran was irritable around people. The August 2011 record also reveals that the Veteran had retired at the age of 62 as he could not do his job anymore. An April 2012 record indicates that the Veteran had been sad and depressed; financial problems and his wife being sick were both noted. In this case, these treatment records do not show impairment in the Veteran's family relations or thinking. Furthermore, although they show that the Veteran left his job, they do not indicate that it was the Veteran's PTSD that rendered him unable to continue with his job. In this regard, a December 2011 record shows that the Veteran had physical health problems including sleep apnea and a left knee disorder for which surgery was being contemplated. As such, these records do not show occupational and social impairment with deficiencies in his work. The Veteran was repeatedly shown to be sad, and some records indicate that he was anxious, indicative of deficiencies in mood. Despite the records showing irritability, they did not indicate that such irritability caused impaired impulse control such as periods of violence. The symptoms shown in these records do not indicate that the Veteran has deficiencies in judgment or thinking. The records reveal little about the Veteran's family relations, except to show that he continued to be married and that his wife was ill. As such, deficiencies in family were not shown. The records do suggest deficiencies in mood as the Veteran was shown to be sad. However, the overall symptomatology shown throughout these records does not indicate show occupational and social impairment with deficiencies in most areas. Symptoms such 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; spatial disorientation; or difficulty in adapting to stressful circumstances were not shown. Considering the fact that he was shown to have little socialization, such records do indicate the inability to establish and maintain effective relationships. However, the overall symptomatology shown in these records does not indicate that the Veteran's PTSD warrants a 70 percent rating. A May 2012 VA examination also does not reveal that the Veteran meets the criteria for a 70 percent rating. A GAF score of 59 was assigned. After examining the Veteran, the examiner opined that the Veteran's PTSD resulted in occupational and social impairment with 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. The Board observes that this level of impairment is that contemplated for by a 30 percent rating under DC 9411. The Veteran reported that he was still married since 1997. He reported that they did "ok" and did not "fuss" too much, but finances did stress them out. He reported that he and his wife did have different levels of social interest and she sometimes did social things without him, while other times he went with her and endured the social interaction. He reported getting along pretty good with the five children (one of whom was nearby) and some grandchildren. The Veteran reported that shorter visits (one day) with them were okay, but for longer visits, he tended to keep to himself due to increased anxiety/irritation. He had one friend who moved away, but he still reported having "a couple" of veteran friends and he reported enjoying gospel music or talking with them. He listened to gospel music and sometimes went to a live performance. He had been to his grandson's high school basketball games at times and attended church. The Veteran tended to avoid places such as the grocery store because everybody knew everybody and he wished to avoid a lot of conversations. He did a little yard work when his knee permitted. Finances also greatly limited his activities. The Veteran took care of household chores and tasks. He and his wife did sometimes go out to eat, but he reported that he preferred to sit with his back to a wall and where he could see others approach him. Since the last April 2009 VA examination, the Veteran reported retiring at age 62 in 2011 and reported that he chose that due to his knee problem. He had worked at an elementary school. The Veteran showed up and did his job okay. He reported that there was stress with the young children because he would often have to re-do what he just cleaned after the kids messed it up, but overall seemed to function adequately at his job. He currently reported doing some part-time yard mowing for two to three people. The examiner noted that VA treatment records showed negative depression screenings in February 2010, September 2011 and April 2012. Examination revealed symptoms including depressed mood; anxiety; chronic sleep impairment; and difficulty in establishing and maintaining effective work and social relationships. The Veteran did not have other symptoms attributable to PTSD other than those listed. He was capable of managing his financial affairs. The examiner noted that the Veteran's affect was within normal limits. Mood ranged from euthymic to mildly dysphoric. While he reported some mild feelings of anxiety about being at the exam, that was not overtly apparent and he seemed relatively at ease. The Veteran interacted normally. Eye contact, behavior and speech were all normal. Memory was intact. There were no delusions or hallucinations; no suicidal or homicidal ideation; and no panic attacks. Impulse control was adequate, with no severe anger outbursts for example. Grooming and hygiene appeared adequate. The Veteran reported that his mood was often low, yet also reported that he was glad to be alive. He reported that he tried to make himself feel better and sometimes he succeeded and sometimes he did not. He seemed to describe himself as a person who held such feelings of low mood (as well as irritation) inside, with good impulse control and he reported others did not often know how he really felt. He reported feeling anxious "at times" and reported that memories of Vietnam did make him nervous. It was also noted that the Veteran indicated a number of times in the exam that he was having significant financial hardship and it was also likely that that current stress also contributed to his anxiety and low mood (just how much could not be measured). Thus, the examination also fails to show that a 70 percent rating is warranted. As noted above, the examiner opined that the Veteran's PTSD impairment was indicative of a 30 percent rating due to occupational and social impairment with 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. The actual symptoms noted during this examination do not equate to 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and the inability to establish and maintain effective relationships. Indeed, the examiner did not indicate that the Veteran experienced any of the symptoms shown in the rating criteria for a 70 percent rating. The Veteran continued to have relationships with his wife and children, and even attended his grandson's sporting events, indicating that he did not have deficiencies in family. The Veteran was no longer working, but reported that he retired due to his knee and not due to PTSD symptomatology. When he was working, although the children at the school he worked in stressed him, he was still able to function adequately. Therefore, deficiencies in work were not shown. There is no indication that the Veteran had deficiencies in judgment or thinking. In considering the Veteran's reports of irritability and sadness, the Board concludes that the Veteran did have deficiencies in mood. However, considering the other symptoms shown on examination, the totality of the evidence fails to show that the Veteran meets the criteria for a 70 percent rating. A November 2012 record from Dr. H.J. also does not reveal that the Veteran's PTSD warrants a 70 percent rating. He reported staying home most of the time with not much energy or desire to go anywhere. He was annoyed by noise and crowd. The Veteran continued to have a problem with focus and concentrating; he avoided any situation, which reminded him of service and his traumatic event; he stayed in the house most of the time with minimum interaction; and he got some depressed at some point and he continued to be anxious. The Veteran was depressed and anxious; affect was constricted; and there was no psychosis or delusions. This record does not contain information regarding the Veteran's relationships with his family members. Although the Veteran continued to be unemployed, considering his physical problems already noted above, this record does not show that the Veteran's PTSD caused deficiencies in work. This record also does not reveal the Veteran's PTSD impairment on his judgment. Even though this record is suggestive of deficiencies in thinking and mood as evidenced by a problem with focus and concentrating, in addition to being depressed and anxious, the overall impairment shown in this record does not equate to a 70 percent rating. None of the symptoms contemplated for by a 70 percent rating were shown, nor does this record reveal occupational and social impairment with deficiencies in most areas, such as work, family relations and judgment. As such, the Board concludes that it is not supportive a 70 percent rating. The totality of the evidence shows that the Veteran's service-connected PTSD does not cause 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; or spatial disorientation. Although the evidence does show that the Veteran has reported irritability, it does not suggest impaired impulse control as the Veteran has not been shown to act on his irritability. There has been no indication of violent or assaultive behaviors. Furthermore, although as the Veteran has few friends, indicating an inability to establish and maintain effective relationships, the evidence does not indicate that such symptoms result in deficiencies in work, school, family relations, judgment, thinking, or mood. Dr. H.J.'s records repeatedly show that the Veteran was disheveled, suggesting neglect of personal appearance and hygiene, the evidence does not indicate that such symptom has resulted in occupational and social impairment. Furthermore, the VA examinations failed to show such a neglect of personal appearance and hygiene. Throughout this appeal, the evidence does not suggest occupational and social impairment with deficiencies in most areas. As already discussed above, deficiencies in work, family relations and judgment have not been shown. Even with evidence suggesting deficiencies in thinking and mood, the Veteran's PTSD was opined to be moderate by VA examiners. As such, the evidence fails to show that a 70 percent rating is warranted. In reaching the conclusion that a rating in excess of 70 percent is not warranted, the Board notes that the reported GAF scores of 54 and 59 are indicative of moderate symptoms, which are consistent with a finding that the Veteran does not have occupational and social impairment with deficiencies in most areas. Although Dr. H.J. reported a GAF score of 40 in 2009, indicative of some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood, the overall symptomatology shown throughout this appeal period does not indicate that the Veteran has such impairment as already discussed above. The Board also notes that, while important, the GAF scores assigned in a case are not dispositive of the evaluation and must be considered in light of the actual symptoms of the Veteran's disorder. See 38 C.F.R. § 4.126(a). In this case, the extent and severity of the Veteran's actual PTSD reported and/or shown are suggestive of occupational and social impairment, with reduced reliability and productivity due to such symptoms as impaired abstract thinking, disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships; i.e., the level of impairment contemplated in the assigned 50 percent rating for psychiatric disabilities. For these reasons, the Board finds that the criteria for a rating in excess of 50 percent for PTSD have not been met. Furthermore, the rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the disability. 38 C.F.R. § 4.1. The Board notes that in exceptional cases where evaluations provided by the rating schedule are found to be inadequate, an extraschedular evaluation may be assigned which is commensurate with the veteran's average earning capacity impairment due to the service-connected disorder. 38 C.F.R. § 3.321(b). However, the Board believes that the regular schedular standards applied in the current case adequately describe and provide for the Veteran's PTSD symptoms and disability level. Marked interference with employment beyond that contemplated by the schedular criteria has not been shown. The record does not reflect a disability picture that is so exceptional or unusual that the normal provisions of the rating schedule would not adequately compensate the Veteran for his service-connected disability. The evidence does not show that the Veteran's PTSD has resulted in interference with employment or activities of daily life which would warrant a rating in excess of 70 percent. Moreover, as the Veteran has not contended, nor does the evidence show that his disability renders him unemployable, the issue of entitlement to a total disability rating based on individual unemployability has not been raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER Entitlement to a rating in excess of 50 percent for PTSD is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs