Citation Nr: 1317329 Decision Date: 05/28/13 Archive Date: 06/06/13 DOCKET NO. 09-47 671 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from May 1968 to March 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Huntington, West Virginia Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Travel Board hearing at the RO before the undersigned Veterans Law Judge in July 2011. A transcript of that hearing has been associated with the claims file. This case was previously remanded by the Board in December 2011 for additional development. As noted in the December 2011 Board remand, the Veteran asserted he was "not employable" due to his service-connected PTSD in the November 2009 Substantive Appeal. The record reflects he was also in receipt of service connection for type II diabetes mellitus. In view of the Veteran's assertion, the issue of entitlement to a total disability rating based on individual unemployability (TDIU) was raised by the record and was REFERRED to the Agency of Original Jurisdiction (AOJ) by the Board in December 2011. See Locklear v. Shinseki, 24 Vet. App. 311 (2011) (although a TDIU and increased rating issues are best analyzed as part of the same claim, bifurcation of the TDIU and increased rating aspects of the claim is generally within the Secretary's discretion). See also VAOPGCPREC 6-96 at para. 12, 13 (August 16, 1996) (if the Veteran asserts entitlement to a TDIU rating based in whole or in part on other service-connected disabilities which were not the subject of the appealed RO decision, referral to the RO, rather than remand, would be the appropriate action). A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records. A supplemental statement of the case (SSOC) was issued in July 2012, which addressed this additional evidence. Following the issuance of the July 2012 SSOC, additional VA medical records were added to the Virtual VA paperless claims file. In a February 2013 informal hearing presentation, the Veteran's representative waived initial consideration by the Appeals Management Center (AMC) or RO of these additional record to avoid a remand purely on that basis. FINDING OF FACT Throughout the duration of the appeal, the Veteran's PTSD symptoms have been productive of not more than moderate symptoms causing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform tasks. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130 Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board will discuss the relevant law which it is required to apply. This includes statutes published in Title 38, United States Code ("38 U.S.C.A."); regulations published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). The Veterans Claims Assistance Act (VCAA) Under the VCAA, VA 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 that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was provided notice under the VCAA in November 2008. The VCAA letter indicated the types of information and evidence necessary to substantiate the claim, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The Veteran also received notice in November 2008, pertaining to the disability rating and effective date elements of his claim and an SOC was issued in September 2009 with subsequent readjudication in July 2010 and July 2012 SSOCs. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Mayfield and Pelegrini, both supra. Service connection for PTSD has been established and an initial rating for this condition has been assigned. The claim has therefore been substantiated. See Dingess v. Nicholson, 19 Vet. App. at 490-491. Notice under the VCAA is no longer required as to this matter, because the purpose for which such notice was intended to serve has been fulfilled. Id. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claim. All relevant evidence necessary for an equitable resolution of the issue on appeal has been identified and obtained, to the extent possible. The evidence of record includes private medical records, VA outpatient treatment reports, VA examinations, and statements and testimony from the Veteran and his representative. The February 2009 and June 2010 VA examination reports reflect that the examiners reviewed the Veteran's medical history, documented his current medical condition, and rendered appropriate diagnoses and conclusions consistent with the remainder of the evidence of record, and with supporting rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Consequently, the medical examinations are adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). This case was remanded in December 2011 to obtain any outstanding medical records of treatment for PTSD. As the Veteran reported he only received treatment at the VA hospital and VA clinic for his PTSD and all VA medical records from January 2009 and thereafter were obtained, the development requested by the December 2011 remand has now been satisfactorily completed. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall, 11 Vet. App. 268 where Board's remand instructions were substantially complied with). During the July 2011 hearing, the Veterans Law Judge explained fully the issues and suggested the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position pursuant to 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). The transcript of the hearing reflects that the Veterans Law Judge identified the material issue - entitlement to an increased rating for PTSD, evaluated at 30 percent disabling. The Veterans Law Judge asked the Veteran whether his memory had become worse since the last VA examination and to provide an example. He also questioned the Veteran on memory later in the hearing, asking about related difficulties with memory and understanding. The Veterans Law Judge also asked the Veteran about his relationships with friends, his wife, children and grandchildren, his hobbies and activities. The Veteran was not prejudiced by the hearing that was provided. See Bryant, 23 Vet. App. at 498 (citing to 38 U.S.C. § 7261(b)(2); Shinseki v. Sanders, 129 S. Ct. 1696, 1704 (2009)). The April 2011 hearing was legally sufficient. The Veteran has not indicated that he has any further evidence to submit to VA, or which VA must obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran has been accorded ample opportunity to present evidence and argument in support of his appeal. VA has obtained, or made reasonable efforts to obtain, all evidence that might be relevant to the issues on appeal, and that VA has satisfied the duty to assist. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2012). The Merits of the Appeal Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, for the reasons discussed below, the Board finds that the preponderance of the evidence is against the claim. 38 U.S.C.A § 5107 (West 2002); Alemany v. Brown, 9 Vet. App. 518 (1996). Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 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 for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in the disorder, it is necessary to consider the complete medical history of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the question for consideration is the propriety of the initial evaluation assigned after the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged ratings" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found - this practice is known as "staged ratings." Id.. The Veteran's PTSD has been assigned a 30 percent evaluation effective November 7, 2008 (the date of his claim), under 38 C.F.R. § 4.130, Diagnostic Code 9411, which is evaluated under the general rating formula for mental disorders. Under this general rating formula, a 30 percent rating for PTSD will be assigned where 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, and mild memory loss. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). A GAF score ranging from 61 to 70 indicates some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, (e.g. occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score ranging from 51 to 60 indicates 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 peer or coworkers). A GAF score of 41 to 50 indicates serious symptoms and serious impairment in social, occupational, or school functioning (e.g., no friends), while a GAF score of 31 to 40 indicates major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). See Diagnostic and Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM-IV). While the Rating Schedule indicates that the rating agency must consider the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Accordingly, GAF scores do not automatically equate to any particular percentage in the Rating Schedule. Rather, they are but one factor to be considered in conjunction with all the other evidence of record. VA outpatient treatment reports from January 2009 to January 2013 reflect that the Veteran's PTSD symptoms included: anxiety; depression; anger and verbal anger outbursts; rage; irritability; sleep difficulty; nightmares; intrusive thoughts; flashbacks; mood ranging from euthymic to anxious and depressed; affect ranging from appropriate to restricted and congruent with mood; normal speech; intact memory; grossly intact cognitive functioning; alertness and orientation in all spheres; no hallucinations, delusions or paranoia; linear, logical and goal-directed thought processes; no suicidal or homicidal ideation; and intact insight and judgment ranging from fair to good. These records reflect that the Veteran was able to maintain close relationships with his wife, children, grandchildren and maintained contact with a group of friends. During this period the Veteran was continually assessed as to not be a danger to himself or others. GAF scores during this period ranged from 60 to 75. A January 2009 VA outpatient treatment report reflects that the Veteran reported having emotional problems for the past 40 years and was interested in seeking treatment. At that time, he also reported having problems with rage. In a March 2009 VA mental health treatment report, the Veteran reported being not as anxious, less irritable and having improved depression. However, the Veteran reported that he continued to have problems with sleep disturbance. At a February 2009 VA examination, the Veteran reported symptoms of periodic sadness, periodic tearfulness and some once-monthly insomnia. He denied having fatigue and reported his motivation was intact. He denied any significant concentration or memory problems. The Veteran stated that he kept to himself much of the time and enjoyed being by himself. He reported having decreased irritability due to decreased social contact since leaving work - the Veteran was then retired. The Veteran stated he only had periodic irritability with his wife, about once a month. No suicidal or homicidal ideation was reported and the Veteran denied any significant guilt, although some was described during the PTSD assessment. The Veteran reported having been married for 40 years and got along with his wife well. He had two sons and reported having a good relationship with them. The Veteran also reported having three grandchildren whom he spent time with. He had a few friends from his former employment with whom he was still in periodic contact and had breakfast with them once a month. The Veteran stated that he went out to dinner with his wife fairly often and the last movie he attended was with his grandchild. He usually took one vacation annually and went to the beach often in the summer. He also reported working on home improvement projects and restoring his car and spending time with his family. He watched some television. There was no history of suicide attempts, violence or assaultiveness. The Veteran had no alcohol or substance use. A psychiatric evaluation revealed that the Veteran was clean, neatly groomed and appropriately and casually dressed. His psychomotor activity and speech were unremarkable. The Veteran's attitude toward the examiner was described as cooperative, friendly, relaxed and attentive. His affect was appropriate and full and he was noted to be in a good mood. The Veteran's attention was intact. Although he was unable to do serial 7's, he was able to spell a word forward and backward and did not report any attention problems in daily life. He was oriented to person, time and place. Thought processes and content were unremarkable. No delusions were found. The Veteran understood the outcome of his behavior and was assessed to be of average intelligence. Sleep impairment was noted. No hallucinations were reported. Inappropriate behavior was noted to include occasional irritability with verbal acting out. There were no findings of obsessive or ritualistic behavior, panic attacks, homicidal or suicidal thoughts. The Veteran's impulse control was fair and he had no episodes of violence. He was able to maintain a minimum personal hygiene. Problems with activities of daily living included slight problems with other recreational activities. Remote, recent and immediate memory was found to be normal. While PTSD symptoms were described as chronic, the occurrence of PTSD symptoms ranged from infrequently, to two to three times annually to once a month. He stated he felt close to family and some friends but reported that he enjoyed being by himself. He had feelings and expressions of love and joy and positive expectations of the future. Other reported symptoms included hypervigilance with crowds, avoidance of crowds, periodic sleep problems and irritability. He reported a history of startle responses, which he believed was beyond what most people would experience and he was generally affected by unexpected loud noises. As to employment status, the Veteran was not currently employed and had retired as a cable splicer from Verizon in September 2006 as he was eligible by age and duration of work and was offered an early retirement. He was assessed a GAF score of 65. The examiner concluded that the Veteran had mild symptoms and functional impairment. The examiner observed that the Veteran had a history of irritability with co-workers, however his irritability did not significantly affect his work. The examiner also noted the Veteran had only occasional irritability with verbal acting out toward his wife and generally had good familial relationships. The Veteran reported having friends, some of whom were as close as "brothers," although the examiner found that he kept social relationships at an "arm's length" and enjoyed spending much time alone. He generally had intact leisure activities. The examiner's prognosis was guardedly optimistic. Finally, the examiner concluded that the Veteran's PTSD signs and symptoms were transient or mild and decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress. In a July 2009 VA outpatient treatment report, the Veteran stated that he did not really have anxiety and that to the extent that he did, improvement with anxiety had been consistent. He stated he still experienced depression, which was intermittent and he continued to experience irritability, anger outbursts and isolated himself from others. A November 2009 VA outpatient treatment report reflects that the Veteran had made significant progress with regard to anxiety and depression since beginning treatment and that his anxiety producing dreams had reduced to only a few times per year and his sleep was much improved. He reported that he was relaxed the majority of the time but continued to experience some problems with irritability around his wife. At that time, the Veteran agreed to termination of his current individual psychotherapy and expressed some interest in seeking marital therapy for relationship problems. In an April 2010 VA mental health treatment report, the Veteran reported having a decrease in both anger and irritability and that he was not withdrawn - he reported that he just liked to be alone. At a June 2010 VA examination, the examiner noted the Veteran had been seen for eight counseling sessions on PTSD and had been seen by VA physicians as well for this disorder. The examiner also noted that the Veteran had been treated for PTSD with counseling and medication since his last VA examination and currently he was taking medication only, with no counseling appointments noted since November 2009. While the examiner noted the Veteran's GAF scores ranged from 55 to 70 since his last examination, his lowest GAF scored were in the 60's range. The examiner also noted the Veteran's most recent encounter described him as meeting treatment goals and being stable on medication. The Veteran reported the effectiveness of therapy had been good and he was sleeping better and had less irritability with medication. He also stated that previous counseling sessions were helpful for insight and symptoms relate to PTSD. The Veteran reported feeling "down in the dumps" a couple of days a week, with crying spells occurring once every month or two. He noted having some fatigue but no loss of motivation. The Veteran also reported having guilt related to PTSD issues. The examiner found the symptoms did not meet the criteria for depressive disorder. The Veteran lived with his wife in a home in Charleston, West Virginia. The Veteran essentially reiterated previously reported information as to dining out, vacation frequency and home projects; as well as the extent of his family relationships. He attempted to walk three to four times per week for his "mental health." The Veteran used to ride motorcycles but stopped upon returning from Vietnam. He preferred to be alone. No history of suicide attempts, violence or assaultiveness was reported. The examiner summarized that the Veteran had been able to maintain relationships with his family but had little socialization beyond this group with exception of the monthly breakfast with his former co-workers. It appeared to the examiner that the Veteran spent most of his time alone as his wife remained in the workforce. No alcohol or substance use was reported. A psychiatric examination revealed that the Veteran appeared clean, neatly groomed and appropriately dressed. His psychomotor activity was restless and his speech was unremarkable. His attitude was cooperative and attentive and he had a full affect and anxious mood. The Veteran was unable to do serial 7's and was able to spell a word forward and backward. He was oriented to person, time and place. His thought processes were unremarkable. Thought content included ruminations. No delusions were found. The Veteran understood the outcome of his behavior and that he had a problem. He was found to be of average intelligence. Sleep impairment was noted and the Veteran reported having middle insomnia a couple of times per week. He reported that, after sleeping for a couple of hours, he awoke and sometimes was able to return to sleep within an hour or two, but sometimes could not return to sleep. His sleep ranged from five to six hours on average. The Veteran was found to interpret proverbs correctly. No inappropriate behavior, obsessive/ritualistic behavior, panic attacks, homicidal thoughts, suicidal thoughts or episodes of violence were found. The Veteran's impulse control was good and he was able to maintain minimum personal hygiene. No problems with activities of daily living were found. The Veteran's remote and immediate memory were normal and his recent memory was found to be mildly impaired. The examiner noted that the Veteran was able to recall five out of five objects on immediate recall and only three out of five objects after five minutes. PTSD symptoms were noted to essentially reiterate those previously reported; and ranging from several times in a year to two times per week. Most symptoms were characterized as mild with little to no disruption of daily activities, however the examiner did find some mild to moderate severity of psychological distress and irritability or anger outbursts and moderate to severe symptoms of trauma dreams and difficulty falling or staying asleep. The examiner found the Veteran was generally reclusive, mostly uncomfortable socializing with people he did not know well and avoided participation in large social gatherings. He noted the Veteran maintained a casual relationship with former co-workers from the job he retired from, and that he had contact with once per month and the Veteran enjoyed a few activities outside the home. He also found that the Veteran avoided most contacts outside of his family; avoided large crowds and did not do any shopping; he ruminated about war zone experiences; he was frequently distracted by intrusive trauma thoughts; he reported and exhibited some concentration problems and short term memory deficits; and he described persistent anxiety and related some depressive symptoms including sad feelings, crying spells, irritability and occasional verbal outbursts, almost always toward his wife. The Veteran reportedly retired in 2006 from working as a cable splicer for a telephone company and retired due to eligibility by age or duration of work. He was assigned a GAF score of 60. The prognosis was fair and the examiner noted the Veteran benefited symptomatically from treatment over the past year but functioning appeared to be at or near the same level. The examiner concluded that the Veteran's PTSD signs and symptoms were transient or mild and decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress, noting the Veteran's social impairment due to anxiety and arousal, social isolation, nightmares, mild concentration and memory deficits, frequent irritability and chronic sleep problems. The Veteran was not assessed to be totally occupationally impaired and was not assessed to be unemployable based solely on mental health symptoms. During a July 2011 Travel Board hearing, the Veteran testified that he was not taking anxiety medication for the previous six or eight months because of erectile dysfunction and that he was not on any mediation for anxiety at that time. When asked by the Veterans Law Judge whether he experienced an increase in symptoms since he was taken off the anxiety medication, the Veteran reported no. The Veteran's representative asked him to provide examples of how his symptoms had worsened since his last examination in 2010, the Veteran answered that "maybe" due to his retirement, he had more time to think. He reported having anxiety. The Veteran testified that he had claustrophobia, which was made worse in the summer heat and that it was always hot when he was stationed in Vietnam. He stated that his memory was not what he thought it should be and that since his last examination he thought his memory had become worse. As examples, the Veteran testified that there were things he did not remember and would have to ask his wife. He also stated that he would forget what he was told and that maybe he did not remember but it seemed as if his memory was much worse. He specified later in the hearing that he had difficulty with understanding what someone was trying to tell him, normally in regard to complex situations. The Veteran testified that he was mostly by himself and did not spend a lot of time around anybody to avoid becoming angry. However, he stated that when he met with friends once a month, they talked about politics which would anger him but he controlled himself. He reported that he sometimes found himself not wanting to meet up with his friends to avoid the social interaction. The Veteran testified that he did not spend time as much time walking in the woods as he used to and he lacked motivation to go out of the house anymore. He stated that although his wife was difficult to get along with, he was not violent to her and they had been married for 43 years. He also testified that he got along with his sons and grandchildren and became distant with two of his grandchildren due to his son's divorce and their moving away. The Veteran testified that his hobbies included fixing up his truck. Finally, he reported that he did not like to go to the store but sometimes went for his wife and that he was not paranoid about being in a store. A November 2011 VA outpatient treatment report noted that the Veteran had not been seen in the mental health clinic since August 2010 and that he had been off anti-depressant medication for a period. A December 2011 VA outpatient treatment report reflects that the Veteran's GAF score was 70 and he had not been on mood medication for management for quite some time. VA outpatient treatment reports from April 2012 to October 2012 reflect that the Veteran reported an improvement in many symptoms. In April 2012 he noted an improvement in mood and less irritability, though he continued to have sleep difficulty, depression, anxiety, anger. In May 2012, the Veteran reported an improvement in mood and was less irritable, depressed and anxious. He also reported having a hobby of collecting, restoring and maintaining antique vehicles. He continued to use avoidance as a coping mechanism with his wife, close friends and family members, and took solace in a private cemetary that was owned by his deceased parents. Mental status evaluation noted that he was in a euthymic mood, which continued in subsequent mental status evaluations through October 2012. During the period from April 2012 to October 2012, the Veteran displayed good hygiene and grooming, anxious behavior and was cooperative. Objective mental status findings throughout this time included: alertness and orientation in three spheres; grossly intact cognition; anxious to euthymic mood; broad, full range, congruent and appropriate affect; coherent speech at normal volume and rate; grossly intact cognitive functioning; organized and goal directed thought processes with no flight of ideas or loose associations; no suicidal or homicidal ideation or intent; no auditory or visual hallucinations; no paranoia; and fair to good insight and judgment. GAF scores during this period ranged from 60 to 75. By October 2012, the Veteran continued to report improvement with symptoms including having good sleep and his mood improved to an eight out of 10, with 10 being great. In January 2013, the Veteran reported his marital problems were a stressor but that he was "OK." He planned to discuss a family therapy referral with his psychotherapist. The Veteran was married for 45 years and briefly discussed the most recent problematic interaction with his wife. Medications were still helpful with his sleep difficulty, although he continued to report having to wake up frequently at night, often needing to void. His mood was reportedly at a seven to eight out of 10 with 10 being great. He stated that, when he was by himself, he was "real good." A mental status evaluation revealed the Veteran was alert and oriented in all four spheres, maintained good eye contact, was casually dressed and displayed socially appropriate behavior. His speech was at a normal rate and volume and his mood was irritable with a congruent affect. Thoughts were goal directed and there were no auditory or visual hallucinations or suicidal or homicidal ideation. Cognitive functioning was grossly intact. Insight and judgment were fair. He was assigned a GAF score of 60. The symptoms of the Veteran's PTSD do not approximate, nor are they akin to any that would support an initial disability rating in excess of 30 percent at any time throughout the duration of the appeal. The probative evidence of record describes the Veteran's PTSD as being reflective of mostly mild symptoms with some moderate symptoms causing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks so as to more nearly approximate the 30 percent criteria, which is currently assigned. The symptoms listed under the 50 percent evaluation criteria are examples of the types and degree of symptoms that would warrant such evaluation, and that the Veteran need not have all of these particular symptoms in order to warrant a 50 percent evaluation. See Mauerhan, 16 Vet. App. 436. However, the criteria described under the 50 percent evaluation reflect a more serious disability, resulting in occupational and social impairment with reduced reliability and productivity, than is demonstrated by the Veteran's PTSD. The record reflects the Veteran's symptoms are representative of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, and include anxiety, depression, irritability, anger, sleep difficulty; nightmares, intrusive thoughts, flashbacks, and mild memory loss, however, these symptoms have been consistently characterized as mild in nature throughout the period of the appeal. While the June 2010 VA examiner found there was mild to moderate severity of psychological distress and irritability or anger outbursts and moderate to severe symptoms of trauma dreams and difficulty falling or staying asleep, both the VA examinations and VA outpatient treatment reports all reflect the Veteran's PTSD signs and symptoms were transient or mild and caused intermittent mild functional impairment. Therefore his symptoms are all consistent within the 30 percent rating criteria currently assigned, and do not approximate symptoms that are such as those either in or akin to those supportive of a higher rating. In addition, the VA outpatient treatment reports reflect that throughout the Veteran's mental health treatment at VA, mental status evaluations revealed objective findings of: mood ranging from euthymic to anxious and depressed; affect ranging from appropriate to restricted and congruent with mood; normal speech; intact memory; grossly intact cognitive functioning; alert and oriented in all spheres; no hallucinations, delusions or paranoia; linear, logical and goal-directed thought processes; no suicidal or homicidal ideation; and intact insight and judgment ranging from fair to good. While recent memory loss was noted in the June 2010 VA examination, this was also characterized by the VA examiner as mild. There can be no doubt that PTSD symptoms have had an effect on his social functioning as evidenced by his avoidance, social isolation and anger and irritability toward his wife. However, the Veteran is not shown to be impaired such that he is difficulty in establishing and maintained effective social relationships. The Veteran is retired from employment, having accepted apparently an offer of early retirement which suggests a rational decision-making process. Apart from his retirement (i.e., employment status) his social functioning is moderately impaired. His VA outpatient treatment evaluations, VA examination and Travel Board hearing testimony all demonstrate he has been able to maintain relationships with former co-workers, reported as being his friends, as well as his familial relations including his wife, sons and grandchildren. While the evidence demonstrates that the Veteran has had irritability and anger toward his wife, such was described by him as being once a month on average and he continued to go out to dinner with her once a week and they went on vacation once a year and went to the beach in the summer. In addition, he had testified in the July 2011 Travel Board hearing that he was not violent with his wife and he went out shopping for her on occasion with no paranoia of being in a store. While the Veteran need not have all of these particular symptoms in order to warrant a 50 percent evaluation per the Court's finding in Mauerhan, his PTSD symptomatology does not demonstrate occupational and social impairment with reduced reliability and productivity due to PTSD symptoms and he has been able to maintain effective social relationships with his family and some friends. See Mauerhan, 16 Vet. App. 436. The evidence demonstrates that the Veteran is isolated and withdrawn from social interaction; however, he continues to maintain relationships with his wife, his two children, his three grandchildren, his daughters-in-law and a group of his friends and former co-workers. In addition, VA outpatient treatment reports reflect that the Veteran's symptoms improved in November 2009 to the point that he was taken off of anxiety medication and ended individual psychotherapy treatment and treatment records in 2012 demonstrate his reported improvement in symptoms including in mood, irritability, anxiety, depression and sleep difficulty. Furthermore, while the Veteran's GAF scores ranged from 60 to 75, evaluations are not assigned based solely upon GAF scores, and the symptomatology described in the record fails to more nearly approximate the criteria for a 50 percent rating at any point during the course of the appeal. Therefore, the probative evidence of record does not demonstrate the Veteran's PTSD has been productive of occupational and social impairment with reduced reliability and productivity so as to more nearly approximate the criteria for a 50 percent disability rating at any time throughout the duration of the appeal. See id. In reaching the above conclusions, the Board has considered the lay statements and testimony by the Veteran with regard to the severity of his service-connected PTSD and in large part has relied on his reports in determining an appropriate disability rating under the benefit-of-the-doubt doctrine. The Veteran is competent to report on factual matters of which he had firsthand knowledge and thus, he is competent to report his current symptomatology as it pertains to his PTSD. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Thus, the Veteran's reports with respect to experiencing symptoms of PTSD have been considered in evaluating his disability rating in this decision. The Veteran's PTSD does not warrant an initial disability rating in excess of 30 percent. The record does not show persistent symptoms that equal or more nearly approximate the criteria for an evaluation in excess of 30 percent at any time since the date of his claim for service connection for PTSD. See Fenderson, 12 Vet. App. at 125-26. The Veteran's disability has been no more than 30 percent disabling since the effective date of his award, so his rating cannot be "staged" because this represents his greatest level of functional impairment attributable to this condition. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. 38 C.F.R. § 4.3; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The benefit sought on appeal is accordingly denied. Extraschedular Consideration At no point since November 7, 2008, the date of the Veteran's claim for service connection for PTSD, has the disability on appeal been shown to be so exceptional or unusual as to warrant the assignment of a rating, higher than that assigned above, on an extra-schedular basis. See 38 C.F.R. § 3.321. The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993); see also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedural Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule 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 regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, 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 extra-schedular rating. Thun, supra. The schedular criteria are adequate to rate the disability under consideration. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than those assigned based on more significant functional impairment should his disability worsen, which, as discussed above, the Veteran's symptoms do not meet. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In this case, the Veteran reported retiring from work in 2006 as due to eligibility based on age or duration of work and the evidence does not demonstrate, and he does not contend, that he has had any periods of hospitalization due to psychiatric symptoms. Accordingly, the record does not demonstrate the Veteran's PTSD is productive of an exceptional disability picture so as to warrant the assignment of a rating, higher than that assigned above, on an extra-schedular basis. See 38 C.F.R. § 3.321e. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial disability rating in excess of 30 percent for PTSD is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs