Citation Nr: 1316263 Decision Date: 05/17/13 Archive Date: 05/29/13 DOCKET NO. 10-07 754 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to September 18, 2009. 2. Entitlement to an initial rating in excess of 50 percent for PTSD on or after September 18, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD G. E. Wilkerson, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1991 to February 2001, from January 2003 to January 2004, and from December 2005 to September 2007. This case comes before the Board of Veteran's Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In that decision, the RO granted service connection for PTSD and assigned a 30 percent evaluation effective from September 20, 2007. During the pendency of the appeal, the RO issued another rating decision in September 2012 and increased the Veteran's disability evaluation for PTSD to 50 percent effective from September 18, 2009. However, 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). In February 2013, the Veteran presented testimony at a Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is of record. At the hearing, the Veteran submitted additional evidence, including various lay statements and a February 2013 PTSD Disability Benefits Questionnaire, along with a waiver of initial RO consideration of the evidence. This evidence has been accepted for inclusion in the record on appeal. See 38 C.F.R. § 20.1304 (2012). A review of the Veteran's Virtual VA electronic claims file reveals additional VA outpatient treatment records dated through May 2012. These records have been considered by the RO, as reflected in the September 2012 rating decision; therefore, a remand for initial consideration of this evidence is not warranted. FINDING OF FACT Throughout the appeal period, the Veteran's PTSD has been productive of occupational and social impairment with reduced reliability and productivity, but he does not have occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood. CONCLUSIONS OF LAW 1. Resolving all doubt in favor of the Veteran, the criteria for an initial 50 percent disability evaluation, but no higher, for PTSD prior to September 18, 2009, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Codes 9411 (2012). 2. The criteria for an initial evaluation in excess of 50 percent for PTSD on or after September 18, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Codes 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). Upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). 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 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 her or his 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 alternative 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 notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Nevertheless, the Veteran in this case is challenging the initial evaluations assigned following the grant of service connection for his PTSD. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8-2003 (December 22, 2003). Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify has been satisfied with respect to the issues on appeal. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. The Veteran has not identified any outstanding records that are available and relevant to the claim being decided herein. Moreover, the record includes various written statements provided by the Veteran and his representative, as well as a transcript of the Veteran's February 2013 Board hearing. ' During the hearing, the undersigned Veterans Law Judge identified the issue on appeal and explained that the focus of the hearing would be on the severity of the Veteran's disability. The Veteran was provided the opportunity to describe how his PTSD affects him, and his functional impairment and current symptoms were discussed. The undersigned Veterans Law Judge also clarified where the Veteran receives his treatment in order to determine whether all relevant records had been obtained. Therefore, the Board finds that it has complied with the duties owed during a hearing. Moreover, the Veteran and his representative have not contended otherwise. The Veteran was also afforded VA examinations in April 2008 and August 2012. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate, as they are predicated on a review of the claims file and all pertinent evidence of record as well as on a mental status examination and fully address the rating criteria that are relevant to rating the disability in this case. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disability since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board concludes the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claim and did in fact participate. Washington v. Nicolson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. II. Law and Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson, the Court noted an important distinction between an appeal involving a veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126. Here, as the RO has already assigned staged ratings for the Veteran's PTSD, the Board will consider the propriety of those ratings, as well as whether any further staged rating of the disability is warranted. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the RO granted service connection for PTSD in an August 2008 rating decision and assigned a 30 percent disability evaluation effective from September 20, 2007. In a September 2012 rating decision, the RO increased the evaluation to 50 percent effective from September 18, 2009. These ratings were assigned pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides that PTSD should be rated under the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. Under the general formula, a 30 percent rating is assigned when 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, mild memory loss (such as forgetting names, directions, recent events). 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. In Vazquez-Claudio v. Shinseki, __ F.3d ___, No. 2012-7114 (Fed.Cir. April 8, 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the 'psychological, social, and occupational functioning on a hypothetical continuum of mental health illness.' There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). At the outset, the Board notes that, in addition to a service-connected PTSD, discussed below, the medical evidence reflects other psychiatric diagnoses-in particular depressive disorder and insomnia. Where it is not possible to distinguish the effects of non-service-connected conditions from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). As there is no indication here that it is possible to distinguish the symptoms from the Veteran's various psychiatric disorders, the Board has considered all of his psychiatric symptoms in evaluating his service-connected PTSD. However, as discussed below in greater detail, the Board has distinguished the symptomatology from the Veteran's service-connected traumatic brain injury from his service-connected PTSD, as indicated by VA examiners. In this case, the Veteran presented for a VA psychiatric examination in April 2008. He indicated that he did not have a history of mental health treatment following discharge from service, but noted that he had difficulties adjusting since returning from his last deployment. His principle difficulties appeared to be related to anger and irritability. He stated that he had been fighting with his wife and yelling at his children, which represented a change in behavior for him. He did not get physical with his temper. The Veteran also reported having sleep disturbances with restless sleep and nightmares, as well as intrusive thoughts of combat stressors from his deployment. The Veteran noted that he experienced hypervigilant behavior in crowded places and in driving situations, along with an exaggerated startle response. He denied having any suicidal ideation, but indicated that he was "not the person [he] was before." With respect to family relationships, the Veteran reported that he had been married to his wife for 17 years and had an increase in irritability since returning from his last deployment. While there had been stress on the relationship, there were no talks of separation or divorce. The Veteran also indicated that he yelled at his two children. In regards to work, the Veteran indicated that he was a full-time student studying criminal justice since his return from service. He reported having feelings of frustration in the classroom, but indicated that his school performance was good. The Veteran presented to the examination as neat, clean, and in casual clothing. He was capable of doing routine activities of daily living. He stated that there were times he preferred to be alone, although he did engage in some social activity both within and outside his immediate family. The Veteran reported alcohol use since November 2007. On mental status examination, the Veteran's immediate and recent memories were satisfactory, and his remote memory was good. He was oriented in all spheres, and his speech was normal as to rate and volume with a discernible increase in level of emotionality when discussing his active duty stressors. His thought process production was spontaneous and abundant, and his continuity of thought was goal directed and relevant. His thought content contained no suicidal or homicidal ideation, and there were no delusions, ideas of reference, or feelings of unreality. The Veteran's abstract ability and concentration were both satisfactory. Subjectively, the Veteran complained of problems with focus and concentration. His mood on examination was anxious, and his range of affect was restricted. He was alert, responsive, and cooperative. His judgment was intact and insight limited. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 55. He indicated that the Veteran's current symptoms included sleep disturbances, nightmares, intrusive thoughts, avoidance behavior, verbal anger, irritability, hypervigilant behavior, occasional exaggerated startle, and complaints of loss of focus and concentration. The examiner also commented that these symptoms appeared to be in the moderate range. A January 2009 VA post-deployment health evaluation reflects that the Veteran worked full-time as a police officer. He reported distancing himself from his civilian friends following his deployment, but indicated that he maintained contact with two Marine friends who were deployed with him and subsequently hired with the same police force. He reported having good friendships with these individuals and noted that his relationships with his family were good. He described having a decreased interest in hobbies and recreational activities. He also denied the regular use of alcohol, but indicated that when he drank to excess when he did consume alcohol. With respect to his psychological symptoms, the Veteran indicated that he had difficulty falling and staying asleep with night sweats and nightmares. He described having a habit of getting up to walk around the house and check on the locks. The Veteran stated that his mood was angry with increased irritability and frustration. He described some symptoms of anhedonia, but denied any feelings of hopelessness or worthlessness. He also reported feeling down on many days. The Veteran had difficulty experiencing the same range of emotions that he had experienced prior to deployment. He denied manic or hypomanic symptoms, as well as suicidal or homicidal ideation. The Veteran indicated that he had irritability, but denied physical or verbal aggression or impulsivity. He also described fear and anxiety when in crowds or while driving, but denied symptoms of panic attacks. With respect to avoidance behaviors, the Veteran reported having a diminished interest or participation in activities, feeling detached or estranged from others, a restricted range of affect and emotional numbness, and a sense or foreshortened future. He also reported having persistent symptoms of arousal, difficulty falling and staying asleep, irritability, difficulty concentrating, and hypervigilance. The examiner observed that the Veteran was neatly dressed and groomed with an apprehensive and anxious mood. He had a full affect that was appropriate to content. He was pleasant and cooperative, and his speech was spontaneous and normal. The Veteran's thoughts were also relevant and coherent, and his insight and judgment were intact. There was no indication of suicidal or homicidal ideation or audio or visual hallucinations or delusions. He was diagnosed with mild to moderate PTSD, and a GAF score of 60 as assigned. The Veteran underwent a cognitive consultation in February 2009 to evaluate his complaints of difficulties remembering tasks and forgetfulness. Test findings revealed a possibility of mild cognitive impairment. It was recommended that he follow-up with mental health to address his stress and PTSD. A February 2009 VA mental health treatment report reflects that the Veteran reported having difficulty readjusting to life following his deployment and stated that he was "ruining relationships" with his wife and daughters due to edginess and irritability. He indicated that he used to be very loving and personable, but now had trouble with intimacy, felt somewhat distracted, and had trouble attending to the needs of his family. He indicated that he was forgetful and could not sleep well. The Veteran experienced intrusive thoughts, as his duties as a police officer reminded him of his time in the Marines and deployment stressors. He also reported hypervigilance and noted that he was always checking for intruders and to be sure that he secured his service weapon after he returned home from work. The Veteran also endorsed survivor guilty. He denied suicidal ideation or violence, but he indicated that he became angry. It was noted that he took Fluoxetine for treatment. The Veteran endorsed drinking more since his return from Iraq. He noted that he was close with his family and two friends who he worked with who had also been previously deployed. During a mental status examination, the Veteran was fully oriented to time, place and person. He was pleasant, cooperative, and had adequate eye contact. His speech had a normal rate, but his mood was down and anxious, and his affect was constricted and worried. There was no evidence of a thought disorder, and his thoughts were relevant and appropriate with no delusions or hallucinations. His judgment was also good, but his insight was limited. The Veteran was diagnosed with PTSD and given a GAF score of 55. An April 2009 VA mental health treatment report reflects that the Veteran returned for a follow-up regarding his PTSD symptoms. He reported feeling about the same, although he acknowledged that his family seemed to think that he was doing better. He was still hypervigilant and anxious and performed a lot of checking of locks and doors and looking in on his children. His sleep was still problematic, and although he did try Zolpidem and found it helped, he had only used it a few times. The Veteran had some exacerbations of reminders of a peer's death in Iraq. He was doing "pretty good" at work, but still had some problems with short-term memory and focus. He indicated that he had only used alcohol once since he was last seen. Objectively, the Veteran was alert, oriented, relevant, neatly groomed and dressed, and cooperative. His mood was somewhat low still, but no suicidal ideation was voiced. There was also no indication of delusions or hallucinations, and he was not irritable. His judgment appeared to be okay, but his insight was still limited. A diagnosis of PTSD with depressive symptoms was assigned. A September 2009 VA outpatient treatment report reflects that the Veteran had not been seen since April and had missed a few appointments. He had not refilled his medication since he was last seen and reported that he was "not too good." He felt ashamed and said his wife felt that he was worse than when he started. He had avoided coming back, but had seen an escalation in irritability at home and at work, had been detaching from friends and family, felt that he had not been able to confide in peers, and did not like the person he had become. His sleep was poor, and he had been using more alcohol-up to 9 beers, 3 to 4 times per week. He said that he, when he used Ambien, he got had benefit and did not use alcohol, but he had not refilled this medication in some time. He had a lot of vigilance and had issues regarding his reminders of combat trauma in July. The Veteran also noted that, when he took his family to Tombstone a few months earlier, he started feeling alarmed and panicky when he saw a shooting display. He denied having any suicidal ideation and violence, but admitted that he felt he overreacted recently when he lost control and spanked his 17-year-old daughter on one occasion. He continued to work as a police officer. On mental status examination, the Veteran was alert, oriented, relevant, neatly groomed, casually dressed, cooperative, and pleasant, but he was also dysphoric and anxious, and depressed. There was no suicidal or homicidal ideation voiced, and he had no intent to harm anyone. His thought process was relevant and intact with no delusions or hallucinations. His judgment was also noted to be "okay" on the whole, but insight was lacking. Diagnoses of PTSD and depression were assigned, along with excessive alcohol use. During VA treatment in March 2010, the Veteran reported having irritability, difficulty concentrating, hypervigilance, intrusive thoughts/memories/perceptions, sleep disturbances, and psychological/physiological distress when faced with memories of his deployment. He also described having avoidance behaviors, emotional numbing, detachment from others, a strong desire to isolate from family and friends, and concerns about his future well-being. He stated that he was struggling in his relationships, especially with his wife and children. These feelings concerned him very much, as he had a history of very close relationships with his family. The Veteran also described some difficulties with work, including a recent work event when he arrived to a scene where an officer had been killed. He stated that he did not feel anything, which he did not think was normal. He stated that his "combat mentality" helped him at work and allowed him to function as needed, and he reported that he was doing well working in the gang unit. However, he noted that he could not shut off this mentality, and as a result, was struggling tremendously at home and in his relationships. While treatment had previously focused on medication management of his symptoms, the Veteran reported that he wanted to try psychotherapy. On mental status examination, the Veteran was neatly dressed and groomed. His mood was "not so good," while his affect was anxious and tense. His speech was normal and spontaneous, his thoughts were relevant and coherent, and his insight and judgment were intact. There was no suicidal or homicidal ideation or any indication of hallucinations or delusions. VA psychiatric treatment in March 2010 reflects that the Veteran presented with worsening symptoms of mood, anger control problems, poor sleep, nightmares, hypervigilance, anxiety, isolation, emotional detachment, and relationship issues with wife and kids as well as co-workers and superiors. He indicated that he and his wife had recently agreed to separate. A mental status examination revealed that the Veteran was alert and oriented to person, place, time, and situation. He was adequately dressed and groomed, and he was polite, cooperative, and provided fair eye contact. His thought processes were generally logical, linear, and goal-directed with no loosening of associations or flight of ideas. He displayed mild psychomotor agitation in gross body movement related to current anxiety, and he described his mood as "not too good" with a congruent depressed, constricted affect. The Veteran denied currently experiencing auditory and visual hallucinations, delusions, or suicidal or homicidal ideations. He appeared to have appropriate cognitive function and memory, and his judgment and insight were also appropriate. Diagnoses of PTSD, depressive disorder, and insomnia secondary these other psychiatric diagnoses were noted. An April 2010 treatment record reflects the Veteran's report of trauma-related nightmares, which had increased in frequency since one of his friends was deployed to Afghanistan; intrusive and recurrent thoughts of the traumas; flashbacks; and both psychological and physiological distress when he saw reminders or triggers. The Veteran also indicated that he tended to avoid reminders, thoughts, feelings and conversations about the trauma. He reported experiencing a sense of detachment from others, as well as a restricted range of affect. The Veteran indicated that he was very close to his family prior to serving in Iraq, but now found that he was pulling away from them. He discussed his family's observations that he was emotionally numb. He also acknowledged that he and his wife recently separated, in part, due to his irritability and emotional detachment. In addition, the Veteran noted that he no longer engaged in activities that he once found pleasurable, such as sports. He indicated that he tends to avoid crowded places and having people stand or sit behind him when possible, as he was hypervigilant to danger in those situations. He also noted that he tended to check the doors and check on his daughters repeatedly at night. The Veteran had difficulty falling and staying asleep and typically got four to five hours of sleep per night. In addition, the Veteran reported that he was easily irritated, had difficulty concentrating, and tended to startle easily to loud noises since coming back from Iraq. The Veteran further reported feeling that his mood was "down" on more days than not, experiencing feelings of anhedonia, and having weight gain, fatigue, and feelings of guilt. He denied any current suicidal ideation and a history of such. In terms of substance use, the Veteran reported that he drank about twice a month, and when he did, he typically drank to excess. On mental status examination, the Veteran was casually dressed and neatly groomed. His mood was anxious with a restricted range of affect. His thought processes appeared logical and goal-directed with no evidence of psychosis. An assessment of PTSD and depression, as well as a GAF score of 55, was documented. A May 2010 report reflects that the Veteran felt some improvement overall in regards to his anxiety. Continued diagnoses of PTSD, depression, and insomnia, along with a GAF score of 55, were noted. A June 2010 VA neurology/traumatic brain injury (TBI) examination reflects that the Veteran complained of sleep impairment, anxiety, and irritability. During a VA neurology examination in October 2011, the Veteran stated that he felt that he was getting worse either from his TBI or psychiatric problems, as he had been getting more irritable and anxious and had to write everything down. He continued to report having sleep difficulty in that he was only able to sleep 4 to 5 hours per night and that sleep was interrupted. He also felt angry all the time. The Veteran further reported experiencing memory problems and some difficulties with attention and concentration. The Veteran was diagnosed with a TBI, and the examiner indicated that the effects of this disability on his usual occupation included memory loss, decreased concentration, and poor social interaction. An October 2011 VA psychiatric treatment report reflects that the Veteran reported for follow-up treatment and was last seen in April 2010. He continued to experience several symptoms of PTSD and depression secondary to PTSD. He endorsed all re-experiencing symptoms (e.g., repeated thoughts of the trauma, nightmares, flashbacks and feelings of psychological distress and physiological arousal upon being reminded of the trauma). The Veteran also endorsed all hyperarousal symptoms and avoidance symptoms. The Veteran indicated that he continued to work as a police officer and discussed how his PTSD symptoms have resulted in difficulty in relationships at work and with his wife and children, which motivated him to seek treatment for PTSD. He reported his current use of alcohol noting that he was drinking several times a week and up to 7 or more drinks per sitting. He reported that he was able to abstain from drinking for long periods of time and has done so in the past. The Veteran was casually dressed and well groomed. His mood was anxious with a restricted range of affect. His thought processes appeared logical and goal-directed, and there was no evidence of psychosis. The Veteran denied having suicidal ideation, and there was no evidence of homicidal ideation. He was diagnosed with PTSD, depression, and alcohol abuse, and the treatment provider assigned a GAF score of 50. A December 2011 VA psychiatric treatment report reflects that the Veteran presented as alert and oriented to person, place, time, and situation. He was adequately dressed and groomed, and he was polite, cooperative, and provided fair eye contact. His thought processes were generally logical, linear, and goal-directed, with no loosening of associations and no flight of ideas. He displayed mild psychomotor retardation in gross body movement related to his current level of back pain. The Veteran described his mood as "angry," but with a depressed, constricted affect. He denied experiencing auditory and visual hallucinations, delusions, and suicidal and homicidal ideations. The examiner commented that the Veteran appeared to be of appropriate cognitive function and memory, and his judgment and insight were appropriate. A GAF score of 55 was assigned. The Veteran reported for counseling sessions beginning in January 2012. In February 2012, the Veteran described an incident at work during which he "went off." He indicated that he had not done so at work before. An April 2012 VA psychiatric report reflect that the Veteran had periods of depression when thinking of all of his medical issues at only 39 years of age. He displayed psychomotor retardation in gross body movement related to his current level of back pain. He described his mood as depressed due to all of his medical problems. Diagnoses of PTSD, depressive disorder, and insomnia related to these diagnoses were assigned. A GAF score of 55 was also assigned. On VA psychiatric examination in August 2012, the Veteran reported many problems with his wife and stated that he became easily angered and agitated with his family. He indicated that his wife had been upset with his appearance of not caring. He stated that he no longer liked to engage in leisure activities and mostly stayed home to read or watch television. He was currently employed and worked 40 hours a week in law enforcement. The Veteran indicated that he had problems with co-workers, such as "snapping more quickly" and getting upset when he felt like he was treated like a child. The Veteran noted that he generally worked better by himself. He also reported having general discomfort working with people and being in big crowds. The Veteran noted that he first saw a mental health provider after his discharge from service. He saw a psychiatrist and was prescribed Burpropion and Ambien. He reported that he slept only a few hours per night and noted that he walked around and checked on the house. The Veteran also reported having memory problems and indicated that he used a notebook to constantly write stuff down. He noted that he has recurring nightmares. He avoided thinking or talking about his traumatic events or reading books or watching television related to the military. He drank alcohol to self-medicate his symptoms and help with sleep. The examiner indicated that the following symptoms applied to the Veteran's diagnoses: depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, anger and irritability, and difficulty in adapting to stressful circumstances. Symptoms, such as spatial disorientation, persistent danger to self or others, neglect of personal appearance, impaired impulse control, illogical or irrelevant speech, obsessional rituals which interfered with routine activities, suicidal ideation, and an inability to establish and maintain effective relationships were denied. The Veteran presented in casual dress and was well-groomed. He had a flat affect and was depressed with a somewhat apathetic mood. He was cooperative and pleasant. The examiner noted that he had participated in treatment, medication management, and therapy with minimal improvement, but was willing and referred for different therapies. The examiner diagnosed the Veteran with PTSD; a depressive disorder not otherwise specified, which was secondary to his medical problems, including a lumbar spine disability; and, alcohol abuse secondary to PTSD symptoms as self-medication, though he had greatly reduced his use. The examiner also noted other medical diagnoses including TBI and lumbar strain. She assigned a GAF score of 50 with GAF scores of 50 to 55 in the past year. With respect to differentiation of symptoms, the examiner noted that many of the Veteran's symptoms could be attributable to both his PTSD and TBI, as well as depression, including memory and sleep problems, agitation, irritability, and depression. She noted that the Veteran's nightmares, startle response, anxiety, and avoidance were due only to PTSD. She also indicated that the Veteran's level of occupational and social impairment due to his psychiatric diagnoses was best described as an 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. She also determined that the Veteran's social and occupational impairment was mainly attributable to PTSD (75 percent), while his TBI accounted for approximately 25 percent of impairment. On a February 2013 PTSD disability benefits questionnaire, a VA physician noted that he reviewed the Veteran's VA outpatient treatment records. He indicated that the Veteran had issues with his spouse due to his depression and PTSD. The examiner noted that the Veteran had worked as a police officer for the past five years and had received work-related formal complaints for irritability and aggressive behavior. While the Veteran previously used alcohol, he had no current use. His current symptoms included a depressed mood, anxiety, suspiciousness, chronic sleep impairment, impairment of short- and long-term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and an inability to establish and maintain effective relationships. The Veteran was diagnosed with PTSD and a depressive disorder not otherwise specified. The examiner noted that the Veteran's neurovegetative symptoms of depression were separate from his PTSD symptomatology. The physician also noted a diagnosis of TBI and indicated that, while there was some overlap of symptomatology, there was likely greater cognitive/memory problem related to his TBI. The physician indicated that the Veteran's level of occupational and social impairment was best described and occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. The examiner noted that, while socialization and relationship impairment was due to PTSD, his cognitive and memory problems were most likely attributable to TBI. In various written statements, the Veteran's wife, daughter, mother, sisters, and niece described the changes in the Veteran's behavior following his deployments. His wife noted that the family frequently had to "walk on eggshells" around him so as to not trigger his anger and irritability. The Veteran's daughter noted that he was very reserved and cold and struggled with negativity and anger. His niece, mother, and sisters all indicated that the Veteran could not be around crowds and was quick to anger. All of these family members described a shift in the Veteran's mood following his discharge from service. During the Veteran's February 2013 Board hearing and in various written statements, he reported difficulty in adjusting since his return from deployment. He noted that he was withdrawn, agitated, and moody and stated that it was difficult for him to keep and maintain relationships. He noted that, while he was still married, he did experience marital difficulties. He had been separated from his wife on occasion and slept on the couch. He noted that he also used to drink heavily, but stopped in November 2012 when he was diagnosed with Crohn's disease. While he was easily startled, the Veteran denied being physically violent or experiencing panic attacks. He did endorse memory problems and intrusive thoughts of war experiences. He denied thoughts of hurting himself or others, and denied suicidal or homicidal ideation. The Veteran noted that he would rather be left alone, but he did have two friends to whom he could relate because they deployed together and have had the same issues since their return. He indicated that he received all treatment at the VA Medical Center and took Wellbutrin or Bupropien as well as Ambien for treatment. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a 50 percent disability evaluation throughout the appeal period beginning on September 20, 2007. The aforementioned evidence reflects that the Veteran's PTSD has been manifested by difficulty sleeping, mood swings, irritability, anger, anxiety, depression, and withdrawal from social activities and relationships. The Board notes that this symptomatology has been present both prior to and following the September 18, 2009, VA outpatient treatment report, which was the basis for the assignment of the increased 50 percent rating for PTSD. This report reflects that the Veteran's symptomatology was worsening in the months leading up to his seeking treatment and notes similar symptomatology, as indicated in previous treatment records and on VA examination. While the Veteran did not demonstrate all of the symptoms listed in the rating formula as indicative of a 50 percent rating, the Board finds that his overall symptomatology picture prior to September 18, 2009, particularly, isolative and withdrawn behavior, symptoms of depression and anxiety, and disturbances in mood, more closely approximate occupational and social impairment with reduced reliability and productivity. Thus, with resolution of all reasonable doubt in the Veteran's favor, the Board finds that his PTSD has more nearly approximates the criteria for an initial 50 percent rating, but no higher, since September 20, 2007. See 38 C.F.R. §§ 4.3 4.7. The Board has also considered whether the Veteran is entitled to an evaluation in excess of 50 percent for his PTSD at any point during the appeal period. As noted above, a 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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); and inability to establish and maintain effective relationships. Here, the evidence does not demonstrate suicidal ideation, and while the Veteran frequently checks the doors and locks to his house, there is no indication of obsessional rituals that rise to the level of interference with routine activities. He has also had normal speech and has been fully oriented. While the Veteran experiences some symptoms of panic and depression, these do not appear to affect his ability to function independently. In addition, the Veteran has consistently denied violent behavior and impaired impulse control, and he has presented for treatment and examination neatly groomed with adequate hygiene. The Board acknowledges the report of the February 2013 VA physician, who indicated that the Veteran was unable to establish and maintain effective relationships and stated that his level of occupational and social impairment led to deficiencies in most area such, as work, family relationship, judgment, thinking, and mood. Such a statement is consistent with the rating criteria for a 70 percent evaluation. However, in this case, the Board believes that the record does not support such findings. While treatment records and examination report reflect that the Veteran experiences difficulties in his relationships due to his PTSD and was separated at one point from his wife, they do not reflect the inability to establish and maintain effective relationships. Rather, the Veteran is still married and has indicated that his family is supportive, despite difficulties in dealing with his PTSD. The Veteran also reported that he has been able to maintain friendships with two individuals who were deployed with him and now work with him. Moreover, the Veteran has been able to maintain full-time employment. Furthermore, there is no evidence of significant impairment in areas, such as thinking or judgment. In fact, there is no history of delusions or hallucinations, and his judgment has been described as intact and fair on mental status examination. In addition, the February 2013 VA physician attributed some of the Veteran's occupational impairment, including cognitive issues and memory problems, to his TBI. This finding is consistent with the findings of the August 2012 VA examiner, who also determined that at least some of the Veteran's occupational and social impairment was due to his TBI. The Board points out that the Veteran has been granted service connection for a TBI and assigned a separate rating for this disability. Thus, to attribute all of the Veteran's impairment solely to PTSD would violate the rule against pyramiding. See 38 C.F.R. § 4.14 (providing that evaluation of the same symptoms under different diagnostic codes is to be avoided). Moreover, the April 2008 VA examiner found that the Veteran's PTSD symptoms were moderate, and the January 2009 VA evaluation determined that he had mild to moderate PTSD. In addition, the August 2012 VA examiner concluded that Veteran's level of occupational and social impairment due to his psychiatric diagnoses was best described as an occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. Based on the foregoing, the Board finds that the Veteran's PTSD symptomatology more closely approximates the criteria for the assigned 50 percent rating for the entire appeal period. As the criteria for a 70 percent rating have not been met, it logically follows that the criteria for a 100 percent rating for PTSD have likewise not been met. The Board notes that, in determining that the criteria for an initial rating in excess of 50 percent for the Veteran's service-connected PTSD are not met, the Board has considered applicable rating criteria not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for the psychiatric disability in question. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Instead, the Board has also considered the extent to which his symptoms have caused occupational and social impairment. Vazquez-Claudio v. Shinseki, __ F.3d ___, No. 2012-7114 (Fed.Cir. April 8, 2013). The Board further notes that none of the GAF scores assigned since the effective date of the grant of service connection, ranging from 50 to 60, alone, provide a basis for assigning a rating in excess of 50 percent for PTSD. According to DSM-IV, a GAF score ranging from 41 to 50 reflects severe 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), while a GAF score ranging from 51 to 60 reflects 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). In this case, the majority of the Veteran's GAF scores have been in the 51 to 60 range, which is indicative of moderate symptomatology and consistent with the 50 percent rating assigned. While the GAF score of 50 assigned by the August 2012 VA examiner and in outpatient records might suggest some impairment greater than that contemplated the initial 50 percent rating assigned, it is but one factor for consideration in assigning a rating in this case. When all of the evidence and findings contained therein are considered, including the degree of functioning as evidenced by these reported scales, the overall evidence does not establish a level of impairment that more nearly approximates a 70 percent or higher rating. As noted above, the Veteran has maintained some relationships and has been employed on a full-time basis with the same employer. Thus, it cannot be said that he has social and occupational impairment with deficiencies in most areas. Accordingly, the Board finds that an initial 50 percent, but no higher, rating for PTSD is warranted for the entire appeal period. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's service-connected PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, which primarily consists of sleep impairment, hypervigilance, isolation, withdrawal, irritability, depression, and anxiety. Indeed, the 50 percent evaluation contemplates the overall effect of all of his symptomatology on his occupational and social functioning. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected PTSD under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Subject to the provisions governing the award of monetary benefits, an initial 50 percent disability evaluation is granted for PTSD for the entire appeal period. An initial evaluation in excess of 70 percent for PTSD is denied. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs