Citation Nr: 1316162 Decision Date: 05/16/13 Archive Date: 05/29/13 DOCKET NO. 08-27 820 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Seattle, Washington THE ISSUE Entitlement to an initial rating for posttraumatic stress disorder (PTSD) in excess of 30 percent. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from March 2003 to December 2005. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2007 rating decision from the Regional Office (RO) in Seattle, Washington, which granted service connection for PTSD and assigned a 10 percent initial rating, effective December 15, 2005. In a September 2010 rating decision during the appeal, the RO granted a 30 percent rating for PTSD, also effective December 15, 2005. A March 2012 Board decision denied an initial disability rating in excess of 30 percent for PTSD. The Veteran thereafter appealed that decision to the United States Court of Appeals for Veterans Claims (Court). The Court's December 2012 Order vacated the Board's March 2012 decision on the issue of an initial disability rating in excess of 30 percent for PTSD and remanded the claim to the Board for readjudication. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. For the initial rating period prior to August 20, 2010, the Veteran's PTSD has more nearly approximated occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: intermittent suicidal ideation, near-continuous depression affecting the ability to function independently, difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. 3. For the initial rating prior to August 20, 2010, the Veteran's PTSD has not more nearly approximated 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; and memory loss for names of close relatives, or for the veteran's own occupation or name. 4. For the initial rating period from August 20, 2010, the Veteran's PTSD has more nearly approximated occupational and social impairment with reduced productivity due to symptoms of depressed mood, anger outbursts, startled response, hypervigilance, disturbing dreams, insomnia, sensitivity to noise, low energy, anxiety, and a decreased ability to form and maintain social and familiar relationships. 5. For the initial rating period from August 20, 2010, the Veteran's PTSD has not been characterized 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. For the initial rating period prior to August 20, 2010, resolving reasonable doubt in the Veteran's favor, the criteria for an initial disability rating of 70 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. For the initial rating period from August 20, 2010, resolving reasonable doubt in the Veteran's favor, the criteria for an initial disability rating of 50 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a timely December 2005 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate the claim as well as what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The notice included provisions for disability ratings and for the effective date of the claim. Because this is an appeal that arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for PTSD, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007). 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date). Regarding the duty to assist, the Board is satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes service treatment records, VA treatment records, and the Veteran's statements. Moreover, the Veteran was also afforded VA psychiatric examinations in March 2007 and August 2010. The Board notes that the VA medical evidence contains sufficiently specific clinical findings and informed discussion of the pertinent history and clinical features of the disabilities on appeal and is adequate for purposes of this appeal. The Board is not aware of, and the Veteran has not suggested the existence of, any additional pertinent evidence not yet received. For the reasons set forth above, the Board finds that VA has fulfilled its duties to notify and assist the Veteran in the appeal under consideration. Adjudication of the claim at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Disability Rating Criteria Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Regarding the evaluations of the Veteran's PTSD, the Board has considered the entire period of initial rating claim from December 2005 to see if the evidence warrants the assignment of different ratings for different periods of time during the claim, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). As the Board will discuss in more detail below, symptoms and social and occupational impairment associated with the Veteran's PTSD are shown to have been more severe prior to March 6, 2007 as evidenced by VA treatment records and a VA examination completed that day. Accordingly, the Board finds that a staged rating is warranted in this case. The Veteran is in receipt of a 30 percent disability rating for PTSD under Diagnostic Code 9411 for the entire initial rating period from December 15, 2005. A rating of 30 percent is warranted for PTSD if there is 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, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is 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); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent disability rating is assigned 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; and memory loss for names of close relatives, or for the veteran's own occupation or name. Id. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2012); Mittleider v. West, 11 Vet. App. 181 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence which does so). In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994) (hereinafter DSM- IV). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. See Mauerhan, 16 Vet. App. 436. Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100 reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). GAF scores from 61 to 70 reflect 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, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). DSM-IV at 46-47. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Initial Rating Prior to August 20, 2010 In the March 2007 rating decision on appeal, service connection was granted for PTSD, and an initial disability rating of 10 percent was assigned, effective December 15, 2005 (the date of the Veteran's initial claim for VA compensation for PTSD). The Veteran entered a notice of disagreement with the initial rating assigned, contending that an initial rating in excess of 10 percent was warranted for his service-connected PTSD. In a September 2010 rating decision during the appeal, the RO granted a 30 percent rating for PTSD, also effective December 15, 2005. The evidence in this case includes VA psychiatric treatment notes dated March 2006 to September 2010. In a March 2006 mental health assessment, the Veteran's affect was anxious. His speech was soft, fluent, and at a normal rate. The March 2006 mental health assessment revealed that the Veteran was sometimes depressed, and that he had thoughts of suicide the previous December (2005), but had no active plan, and that some days he felt OK. A GAF score of 60 was assigned, indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 32. The Veteran was afforded a VA psychiatric examination on March 6, 2007. The VA examiner interviewed the Veteran and reviewed the medical evidence of record. During the examination, the Veteran reported symptoms of depression, sleep impairment, flashbacks, and nightmares. At times, the Veteran reported feeling back in a war zone (e.g. Veteran thought someone was shooting a weapon when fire crackers were set off near his apartment causing him to feel like he was back in Iraq). The Veteran further reported periods of anxiety with heart palpitations and a sensation of chocking. Upon mental status examination, the examiner noted that articulation and speech showed no problems. Affect and mood were appropriate. There were no reports of suicidal, homicidal, or delusional ideas. The examiner diagnosed the Veteran with Axis I chronic PTSD and assigned a GAF score of 55, indicative of moderate PTSD symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 32. In an April 2007 VA psychiatric assessment, the Veteran's affect was congruent with mood. Speech was of normal rate and rhythm, and insight and judgment were good. The GAF score was noted as 70, indicative of mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well. A May 2007 VA mental health assessment reflects that the Veteran described his depression as moderate to heavy at times. The Veteran described PTSD symptoms of sadness, anhedonia, fatigue, panic attacks, and worthlessness since about 2004. The Veteran also acknowledged other symptoms, but described them as variable rather than frequent or consistent (sleep difficulties, agitation, changing appetite, and indecisiveness). The Veteran reported struggling to find employment and developing a post-military identity. Upon mental status examination, the VA psychologist assessed the Veteran as having coherent thought process that was content-directed. His judgment was good and his insight was fair. The Veteran was also found to have a good memory for recent events. The May 2007 VA psychologist assigned a GAF score of 45, indicative of serious symptoms or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See DSM-IV at 32. In an August 2007 mental health note, the Veteran reported exacerbated PTSD symptoms. The Veteran talked about quitting his job because he was asked to do unarmed patrols in dangerous areas. He reported experiencing more fight or flight sensations and more irritability. The Veteran also described an incident where he wanted to attack an individual, but his friends intervened and averted the altercation; however, he was concerned about his loss of control. He also described an incident where his wife and he were arguing and she hit him in the face, cutting his cheek. The Veteran denied losing control with his wife and just walked away. The Board notes that the August 2007 VA treatment record was the last psychiatric treatment note for PTSD until the VA psychiatric examination in August 2010. The Board finds that the absence in psychiatric treatment for over three years has some tendency to show reduced need for treatment, thus requiring less psychiatric care, which is suggestive of improvement in the PTSD symptoms. On the other hand, the absence of medical treatment does not constitute, in itself, negative evidence weighing against the claim, especially since the Veteran has stated that his symptoms have continued since approximately 2004. See August 2010 VA examination report; see also Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). Accordingly, the Board will interpret the absence of treatment during this period most favorably to the Veteran to find that the Veteran's PTSD symptom and social and occupational impairment continued without improvement, so were relatively consistent, from August 2007 to the time of a VA psychiatric examination on August 20, 2010 that reflects the Veteran's degree of occupational and social impairment and symptoms at that time. The Veteran was afforded a second VA psychiatric examination on August 20, 2010. During the interview process, the Veteran reported current symptoms of depressed mood, anger, startled response, disturbing dreams, insomnia, sensitivity to noise, avoidance in socializing, low energy, anxiety, low productivity at work, and a decreased ability to form and maintain social and familiar relationships. The Veteran also reported that his symptoms affect his total daily functioning which result in marital conflicts and loss of interest in pleasurable activities. The VA examiner assessed that the severity of the symptoms were "moderate." Upon mental status examination, the August 2010 VA examiner noted that the Veteran's appearance, hygiene, and behavior were appropriate. Affect and mood showed a flattened affect and depressed mood. The Veteran's affect was noted as flat and weary. Communication, speech, and concentration were within normal limits. Panic attacks were present and reported as occurring less than once per week. The Veteran's thought process, judgment, and abstract thinking were normal. Memory was noted as mildly impaired based on the Veteran's forgetfulness of names, directions, and recent events. Suicidal and homicidal ideation was absent. The VA examiner noted that there were behavioral, cognitive, social, affective or somatic symptoms attributed to PTSD which were described as avoiding social activities, public places, inability to feel a wide range of emotions, hypervigilance, recurrent thoughts, irritability and anger. The VA examiner diagnosed Axis I PTSD and assigned a GAF score of 65, indicative of mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well. See DSM-IV at 32. The August 2010 VA examiner further noted that the Veteran had frequent disputes with his wife, low motivations for the future, and avoidant of social interactions. The effects of PTSD symptoms on the Veteran's employment and overall quality of life included giving up hope to become a police officer after he failed the test partially due to his PTSD symptoms. It was noted that the Veteran felt hopeless and loss of motivation about his future. The VA examiner further stated that the Veteran occasionally had some interference in performing activities of daily living because of his PTSD symptoms, as he occasionally suffered from lowered energy and motivation. The VA examiner reported that the Veteran had difficulty establishing and maintaining effective work/school and social relationships, and often has difficulty reaching out to establish and maintain social relationships. The Veteran was also noted as having difficulty maintaining an effective family role because of his anger and irritability, as evidence d by his strained marital relationship. The VA examiner further stated that the Veteran had occasional interference with recreational or leisurely pursuits because of his decreased motivation associated with PTSD. Based upon review of all the lay and medical evidence of record, the Board finds that prior to August 20, 2010 (the date of the most recent VA examination) the evidence is at least in equipoise as to whether the Veteran's PTSD symptoms were productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD more nearly approximates a 70 percent disability rating for the initial rating period prior to August 20, 2010. As discussed in detail above, VA psychiatric examinations prior to August 20, 2010 and VA mental health treatment notes dated March 2006 to August 2010, which are the most probative evidence for rating for this period, reveal that the Veteran experienced deficiencies in most areas, including work, family relations, and mood. Specifically, the Veteran reported thoughts of suicide in December 2005, he reported numerous complaints of depression and panic attacks, struggled to find employment, had marital problems; and experienced impaired impulse control (Veteran reported experiencing more fight or flight sensations and more irritability and described an incident where he wanted to attack an individual). In addition, the Board notes that for the period prior to August 20, 2010 the Veteran's GAF scores ranged from 45 to 70. In the VA psychiatric examination dated March 2007, the Veteran's GAF scores was 55. In a March 2006 VA mental health treatment note, the Veteran's GAF score was 60; in an April 2007 assessment, the GAF score was 70; and in May 2007 his score was 45. The Board finds that the majority of GAF scores were in the moderate range for assessing PTSD symptoms, with one score (45) reflecting serious symptoms or serious impairment in social, occupational, or school functioning, and one score (70) reflecting mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well. Accordingly, resolving reasonable doubt in the Veteran's favor, the Board finds that a 70 percent disability evaluation for PTSD is warranted for the initial rating period prior to August 20, 2010. The Board further finds that, for the initial rating period prior to August 20, 2010, the Veteran's PTSD did not more nearly approximate a 100 percent disability evaluation. The Board finds that the Veteran's PTSD symptoms do not demonstrate 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; and memory loss for names of close relatives, or for the veteran's own occupation or name. See 38 C.F.R. § 4.130. For example, the Veteran was employed since approximately 2008, his communication, thought process, concentration, memory, and behavior have been generally within normal limits. The Board acknowledges that, in an August 2007 mental health note, the Veteran described an incident where he wanted to attack an individual, but his friends intervened and averted the altercation. He also described an incident where his wife and he were arguing and she hit him in the face, cutting his cheek. The Veteran denied losing control with his wife and just walked away. The Board finds that this evidence demonstrates that the Veteran has, to a certain extent, been able to control his behavior and has used good judgment even in the presence of irritability and anger. The Board also acknowledges that the Veteran experienced suicidal ideations in December 2005, but denied any such thoughts in a March 2006 VA treatment note. For these reasons, the Board finds that for the initial period prior to August 20, 2010, a higher initial rating of 70 percent, but no higher, for PTSD is warranted. Initial Rating from August 20, 2010 As mentioned above, the Veteran was afforded a VA psychiatric examination on August 20, 2010. The Veteran reported symptoms of depressed mood, anger, startled response, disturbing dreams, insomnia, sensitivity to noise, avoidance in socializing, low energy, anxiety, low productivity at work, and a decreased ability to form and maintain social and familiar relationships. The Veteran also reported that his symptoms affect his total daily functioning which result in marital conflicts and loss of interest in pleasurable activities. The VA examiner noted that the severity of the symptoms were moderate and assigned a GAF score of 65, indicative of mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well. See DSM-IV at 32. The August 2010 VA examiner further noted that the Veteran had frequent familiar relationship issues (disputes with his wife) and was noted as having difficulty maintaining an effective family role due to anger and irritability issues. The Veteran also reported decreased motivation at work (Veteran gave up hope in becoming a police officer after he failed the test partially due to his PTSD symptoms). The VA examiner further stated that the Veteran occasionally had some interference in performing activities of daily living because of his PTSD symptoms, (lowered energy and lower motivation). The VA examiner reported that the Veteran had difficulty establishing and maintaining effective work/school and social relationships, and often has difficulty reaching out to establish and maintain social relationships. In a subsequent VA mental health note dated September 2010, the Veteran reported an increase in mental health symptoms which were impacting his marriage. He reported hypervigilance and emotional numbing. The Veteran's affect was noted as being congruent with his mood, his mood was dysphoric. Thought process was organized and linear. The VA psychologist noted mild to moderate PTSD symptoms and assigned a GAF score of 65, reflecting mild PTSD symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well. See DSM-IV at 32. Based upon review of all the lay and medical evidence of record, the Board finds that for the period after August 20, 2010, the evidence is at least in equipoise as to whether the Veteran's PTSD symptoms are productive of occupational and social impairment with reduced reliability and productivity for the initial rating period after August 20, 2010. As discussed in detail above, the August 2010 VA psychiatric examination and the September 2010 VA treatment note reveal that the Veteran has experienced symptoms such as: depressed mood, anger outbursts, startled response, hypervigilance, disturbing dreams, insomnia, sensitivity to noise, low energy, anxiety, and a decreased ability to form and maintain social and familiar relationships. Therefore, resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD more nearly approximates a 50 percent disability rating for the initial rating period after August 20, 2010. The Board further finds that, for the initial rating period from August 20, 2010, the Veteran's PTSD has not been characterized 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships Here, the Board finds that, for the initial rating period from August 20, 2010, the Veteran's PTSD symptoms do not demonstrate occupational and social impairment in most areas, such as work, school, family relations, judgment, thinking, or mood. See Vazquez-Claudio v. Shinseki, 2012-7114 (Fed. Cir. Apr. 8, 2013) (finding that although the veteran's symptomatology is the primary consideration, § 4.130 also requires an ultimate factual conclusion as to the veteran's level of impairment in "most areas"). For example, although the Veteran reported in the July 2007 VA psychologist note that he had lost his job due to PTSD symptoms, during the August 2010 VA evaluation the Veteran reported that he had been working as a security guard at a military base. While the Veteran thought he had low productivity at work, the Veteran reported that his relationship with his supervisor was OK and his relationship with his co-workers was OK. Moreover, he reported that while performing this job he had not lost any time from work. The August 2010 VA examiner assessed that the Veteran was able to perform basic daily activities including full-time work. Further, the August 2010 VA examiner assessed that the Veteran was able to understand directions, had no slowness of thought or confusion, and that thought processes were appropriate. He also noted that the Veteran's judgment was not impaired and that abstract thinking was normal. The Board finds that the August 2010 VA examination and the VA mental health treatment notes reflect impairment primarily family relations as evidenced by the Veteran's marital issues. The Board further finds that the Veteran has also occasionally demonstrated a flattened affect and depressed mood or disturbance of motivation and mood; however, the August 2010 examiner noted that suicidal ideation and homicidal ideation were absent. The September 2010 VA mental health note revealed that mood was dysphoric. For these reasons, the Board finds that for the period after August 20, 2010, the Veteran's disturbances in motivation and mood are not near-continuous as contemplated by the 70 percent rating criteria. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA's general rating formula for mental disorders is 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; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. Id. at 442. With this in mind, the evidence shows that the Veteran's overall PTSD picture for this period is adequately contemplated by the 50 percent rating granted herein. The Veteran does suffer from sleep problems, but this is specifically listed under the criteria for even a 30 percent rating, as are depression and anxiety, which are both symptoms contemplated under the 30 percent PTSD disability rating. Flattened affect, disturbance of motivation and mood, and difficulty in establishing and maintaining relationships are specifically contemplated in the 50 percent rating criteria. Further, the Veteran's depression has not been shown to be "near-continuous" as contemplated by the 70 percent PTSD rating criteria. The Veteran's reported panic attacks, occurring less than once per week, are adequately contemplated under the 30 percent PTSD rating criteria (70 percent rating contemplates near-continuous panic affecting the ability to function independently, appropriately and effectively). Further, the record shows that the Veteran's self-care and conversation are normal. The August 2010 VA examination report showed that the Veteran's thought process was generally logical, relevant, and goal directed. The GAF scores after August 2010 have both been 65. See August 2010 VA examination and September 2010 VA treatment note. A GAF score of 65 contemplates only mild PTSD symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. See DSM-IV at 32. The Board finds that all the evidence of record, including the assigned GAF scores, do not demonstrate occupational and social impairment in most areas such as work, school, family relations, judgment, thinking, or mood for this period. Accordingly, the Board finds that a disability rating in excess of 50 percent is not warranted for the initial rating period after August 20, 2010. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted for PTSD. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that all the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, for the initial rating period prior to August 20, 2010, the Veteran's PTSD was manifested by intermittent suicidal ideation, near-continuous depression affecting the ability to function independently, difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. After August 20, 2010, the Veteran's PTSD is manifested by depressed mood, anger outbursts, startled response, hypervigilance, disturbing dreams, insomnia, and sensitivity to noise, low energy, anxiety, and a decreased ability to form and maintain social and familiar relationships. These symptoms and impairments are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with an acquired psychiatric disorder, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER A higher initial disability rating for PTSD, of 70 percent for the period prior to August 20, 2010, and 50 percent from August 20, 2010, but no higher, is granted. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs