Citation Nr: 1317635 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 10-29 830 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to September 16, 2011. 2. Entitlement to a rating in excess of 50 percent for PTSD, from September 16, 2011. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD M. McPhaull, Counsel INTRODUCTION The Veteran served on active duty from March 1967 to April 1971. This appeal to the Board of Veterans' Appeals (Board) arises from a December 2009 rating decision in which the RO continued a 30 percent rating for PTSD. In January 2010, the Veteran's representative filed a notice of disagreement (NOD) on behalf of the Veteran. A statement of the case (SOC) was issued in April 2010. The Veteran's representative filed a substantive appeal (via a statement accepted in lieu of a VA Form 9, Appeal to the Board of Veterans' Appeals) in June 2010. In July 2011, the Board remanded the claim on appeal for additional development, to include obtaining outstanding pertinent treatment records; as well as a contemporaneous VA examination. In a May 2012 rating decision, the Veteran was assigned a 50 percent rating effective from September 16, 2011 (the date of the VA examination). Although the RO granted a higher, 50 percent rating for PTSD from September 16, 2011, as higher ratings for PTSD are available as before and after that date, and a veteran is presumed to seek the maximum available benefit for a disability, the Board has characterized the appeal as to higher ratings for PTSD as now encompassing the matters set forth on the title page. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. The Veteran's Virtual VA electronic claims folder was reviewed in connection with this claim. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each matter herein decided have been accomplished. 2. Prior to September 16, 2011, the Veteran's psychiatric symptoms reasonably included nightmares, insomnia, irritability, worry/fear, some impaired judgment, occasional disturbances of motivation and mood, impaired immediate memory, and occasional outbursts of anger; collectively, these symptoms suggest occupational and social impairment with reduced reliability and productivity. 3. Since September 16, 2011, the Veteran's psychiatric symptoms have primarily included irritability, impaired thinking and judgment, depression, anxiety, nightmares, flashbacks, periods of violence, avoidance, isolation and frequent panic attacks, neglect of personal appearance, and obsessional rituals which interfere with routine activities; collectively, these symptoms are indicative of no more than occupational and social impairment with deficiencies in most areas. 4. At no point prior to or since September 16, 2011 have the symptoms associated with the Veteran's PTSD been shown to result in 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. 5. The schedular criteria are adequate to rate the Veteran's PTSD at all points pertinent to this appeal. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, a 50 percent, but no higher, rating for service-connected PTSD, for the period from September 3, 2009 through September 15, 2011, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code (Code) 9411 (2012). 2. Resolving all reasonable doubt in the Veteran's favor, a 70 percent, but no higher, rating for service-connected PTSD, from September 16, 2011 is met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In a pre-rating October 2009 letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate a claim for an increased rating. The letter also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. The December 2009 rating decision reflects the initial adjudication of the claim after issuance of the October 2009 letter. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records. Pertinent medical evidence associated with the claims file consists of service, VA treatment records, Social Security Administration records, and the report of VA examinations. Also of record and considered in connection with this matter are statements provided by the Veteran. The Board finds that no additional RO action to further develop the record in connection with the claim, prior to appellate consideration, is required. In sum, VA's duties to notify and assist have been considered and satisfied. Through various notices of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate the claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with either claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. at 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Factual Background The Veteran contends that his PTSD is more disabling than reflected cases the current ratings assigned. Initially, the Board notes that all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal, has been reviewed. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. SSA records reflect that the Veteran has been in receipt of disability benefits since October 2006 with a primary diagnosis of disogenic and degenerative back disorder and secondary diagnosis of pulmonary, chronic insufficiency. A September 2009 VA psychiatric treatment record reflects that the Veteran reported ongoing difficulties with angry outbursts, problems with concentration, intrusive thoughts, problems with sleeping, and intermittent feelings of hopelessness and helplessness. On mental status evaluation, the Veteran was alert and oriented in all spheres; he was well dressed and appropriately groomed; his thought process was normal; he denied any suicidal or homicidal ideation; his concentration was intact during the interview. Diagnoses were PTSD and depressive disorder, and a GAF score of 45 was assigned. On November 2009 VA psychiatric examination, the Veteran reported current assaultive feelings. He reported that he is constantly either hurting somebody or almost about to hurt somebody, including women. He reported several instances in which he is suicidal but with no intent; he reported that he was not in a relationship, however he was involved in Internet dating. The Veteran reported having a good relationship with his son and daughter. Mental status evaluation revealed, that the Veteran was casually dressed and appropriately groomed; his speech was loud, but normal in rate; he exhibited good eye contact; he was oriented in all spheres; there was no obvious impairment of the Veteran's attention and concentration; he reported problems with concentration; he reported being distracted with conversations; his communication was coherent but extremely tangential and circumstantial, and was not able to be redirected; he denied hallucinations, delusions, obsessions, and compulsions; the Veteran reported ongoing intrusive thoughts and distressing memories about his time in Vietnam; he reported nightmares; he reported sleeping difficulty; he has ongoing irritability and angry outbursts at people; there was intermittent episodes of being easily startled and feeling hopeless and helpless. The diagnoses were PTSD, moderate, chronic, without remission; generalized anxiety disorder without panic and agoraphobia, and the GAF score was 50. The examiner noted in pertinent part that the GAF score of 50 was based on the Veteran's moderate symptoms of PTSD and the impact that it has on his life, as well as the diagnosis of generalized anxiety disorder. In a January 2010 statement, the Veteran reported that he stays home all of the time except the first and third Wednesday of each month when he goes out to pay bills and buy groceries. He stated that he experiences severe problems with sleeping. An August 2010 VA Behavioral Health treatment record, reflects that the Veteran reported that he continues to struggle with heightened PTSD symptoms of insomnia, hypervigilance, excessive worry/fear, intrusive memories and thoughts, and nightmares. Mental status examination revealed that he was casually dressed, however a little unkempt; he was cooperative; he exhibited good eye contact; he had a worried mood; his affect was teary; his speech was pressured; he denied suicidal and homicidal ideation; his thought process was logical; he denied hallucinations and delusions; his judgment was influenced by fear and worry. No GAF score was assigned. A November 2010 VA psychiatry outpatient treatment record notes that the Veteran denied mood swings, delusions, hallucinations, suicidal/homicidal ideation, and startling behaviors. The Veteran reported continued nightmares and occasional flashbacks. Mental status evaluation revealed the Veteran was groomed and dressed appropriately; he was oriented in all spheres; his thoughts were goal directed; his speech was spontaneous; his judgment was fair. No GAF score was assigned. In connection with VA outpatient treatment in June 2011 and August 2011, a GAF score of 55 was assigned each time. On VA psychiatric examination conducted on September 16, 2011, the Veteran continued to report sleep difficulties, irritability and outbursts of anger, difficulty concentrating, hyervigilance, exaggerated startle response. The Veteran reported that he has a few friends with whom he visits with. He also reported that he no longer trusted his family members and that he was suspicious of everyone. The Veteran stated that he felt as if he were going to have a nervous breakdown. The Veteran was noted to have not worked in three years, and that he left the workforce due to physical problems. Mental status evaluation revealed the Veteran exhibited a depressed and anxious mood; suspiciousness; panic attacks that occurred weekly; there was sleep impairment; mild memory loss; flattened affect; difficulty in understanding complex commands; impaired judgment and abstract thinking; disturbances in motivation and mood; difficulty in establishing and maintaining effective work and social relationships; impaired impulse control; persistent danger of hurting self or others; neglect of personal appearance and hygiene; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner remarked that the Veteran's symptoms of PTSD appear to have worsened since his last examination. The examiner noted that the Veteran exhibited occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. A GAF score of 40 was assigned. III. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings 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). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Historically, in an August 2007 rating decision, the RO granted service connection for PTSD and an initial 30 percent rating was assigned, effective March 7, 2007. In September 2009, the Veteran submitted his claim for increase. A December 2009 rating decision continued the 30 percent rating. In a May 2012 decision, the RO awarded a 50 percent rating, effective from September 16, 2011. As the RO has already assigned staged ratings for the Veteran's PTSD, the Board will consider the propriety of the rating assigned at each stage, as well as whether any further staged rating of the disability is warranted. The RO assigned the ratings for the Veteran's PTSD under Diagnostic Code 9411. However, the criteria for rating psychiatric disabilities other than eating disorders are actually set forth in a general rating formula. See 38 C.F.R. § 4.130. Under the formula, a 30 percent rating is assigned for 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 (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. Use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on a Veteran's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). 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. 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. A. Period Prior to September 16, 2011 Considering the evidence of record in light of the above, and resolving all reasonable doubt in the Veteran's favor, the Board finds that a 50 percent, but no higher, rating for the Veteran's PTSD is warranted from the September 3, 2009 date of filing of the claim for increase through September 15, 2011. The Board notes that clinical findings on the November 2009 VA examination, as well as ongoing outpatient psychiatric records, document manifestations such as sleep difficulties, and nightmares and flashbacks twice a week. He also exhibited anxiousness and worry, and other PTSD symptoms such as hypervigilance, increased startle response, and avoidance of trauma related stressors collectively were noted. Socially, he generally preferred to be alone, indicating that he had a history of being assaultive to others to include women. Thus, for the period in question, the Veteran's PTSD was manifested by nightmares, insomnia, irritability, some social isolation, panic attacks, some impaired judgment, occasional disturbances of motivation and mood, impaired immediate memory, and occasional outbursts of anger. Collectively, these symptoms suggest occupational and social impairment with reduced reliability and productivity, consistent with the level of impairment contemplated in a 50 percent rating. While the Veteran has not demonstrated all of the symptoms listed in the rating schedules as the type and extent or severity of symptoms warranting a 50 percent rating, the Board is well aware that not all of the demonstrative symptoms must be shown to warrant a higher rating. See Mauerhan v. Principi, 16 Vet. App. 436 2002). In this case, the Board finds that the Veteran's overall symptomatology picture, to particularly include his symptoms of excessive worry and fear, flashbacks, social disturbances and sleep issues including nightmares and poor sleep, support assignment of the 50 percent rating from September 3, 2009 filing of the claim for increase. At no point during the period prior to September 16, 2011, did the Veteran manifest the type and extent or severity of psychiatric symptoms meeting the criteria for at least the next higher, 70 percent rating. However, the objective medical evidence does not show such symptoms as near continuous panic attacks, illogical speech, and depression to the level that it affected his ability to function independently or spatial disorientation or obsessional rituals that are characteristic of the 70 percent rating. Rather, the medical evidence of record for this period indicates that the Veteran occasionally socialized with friends via the Internet, and had a good relationship with his son and daughter. Thus, the Veteran was able to maintain social and family relationships. While the Veteran had long since stopped working, the evidence indicated that this was due in large part to his physical disabilities. The Board acknowledges that the medical evidence from this period reflects that the Veteran's appearance was somewhat unkempt and disheveled and that he experienced suicidal ideation. However, the evidence does not reflect neglect of appearance and hygiene or suicidal ideation to the level contemplated in the 70 percent rating. Rather, while suicidal ideation was endorsed, the Veteran indicated that these thoughts were passive, and that he had no intent or plan. While the Veteran's hygiene was described as "unkempt" on VA outpatient treatment in August 2010, he was noted to be well-groomed and appropriately dressed on VA outpatient treatment in November 2010. Thus, for the period prior to September 16, 2011, the Veteran's PTSD more nearly approximated the criteria for the 50 percent rather than 70 percent rating. See 38 C.F.R. § 4.7. As the criteria for the next higher, 70 percent, rating are not met, it follows that the criteria for an even higher rating (100 percent) likewise are not met. The Board further finds that none of the GAF scores assigned prior to September 16, 2011 provides a basis for assignment of a rating greater than 50 percent. As indicated, the Veteran was assigned the following scores during this period: 45 on VA psychiatry intake examination in September 2009, 50 on VA examination in November 2009, and 55 in connection with VA outpatient treatment in June 2011 and August 2011. According to DSM-IV, scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Under the DSM-IV, GAF scores from 51 to 60 are indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers). The Board finds that the assigned GAF score of 55, indicating overall moderate symptoms/impairment, is consistent with no more than the currently assigned 50 percent rating. Indeed, as score seems to suggest even less impairment than that contemplated in the rating herein assigned, it clearly provides no basis for an even higher rating. Comparatively, the GAF scores of 45 and 50, which are both within the range of scores indicative of serious symptoms/impairment, are essentially consistent with the 50 percent rating herein assigned. Accordingly, under the circumstances of this case, and with all resolution of all reasonable doubt in the Veteran's favor, the Board finds that, for the period prior to September 16, 2011, a 50 percent, but no higher, rating for the Veteran's PTSD, are met. In reaching this conclusion, the Board has favorably applied the benefit-of-the-doubt doctrine, but finds that the preponderance of the evidence is against assignment of any higher rating. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). B. Period From September 16, 2011 Considering the above-cited evidence in light of the applicable criteria, and resolving all reasonable doubt in the Veteran's favor, the Board finds that, for the period beginning on September 16, 2011, the Veteran's PTSD has most closely approximated the criteria for a 70 percent disability rating. As of the VA examination on that date, a worsened psychiatric picture has been demonstrated. Noted psychiatric symptoms include irritability, impaired impulse control and periods of violence, chronic impairment sleep, frequent panic attacks, depression and anxiety. The pertinent VA examination report notes impaired thinking and judgment, some neglect of personal appearance, and obsessional rituals which interfere with routine activities. Collectively, such symptoms are suggestive of occupational and social impairment with deficiencies in most areas-the level of impairment contemplated in the 70 percent disability rating. While the Veteran has not exhibited all symptoms of the type and extent or severity include among the rating criteria for a 70 percent rating, again, the Board notes that such is not required. See Mauerhan, supra. Here, the Board finds that the record reflects sufficiently worsened psychiatric symptoms to resolve reasonable doubt in the Veteran's favor in determining that the criteria for the next higher, 70 percent, rating are met as of the date of VA examination. However, the criteria for the maximum 100 percent rating are not met at any point since September 16, 2011. The Veteran is not shown to have persistent delusions or hallucinations, or grossly inappropriate behavior. While the examiner noted that the Veteran is shown to be a persistent danger to himself or others, there is no indication that he has a plan to harm himself or others. Further, total occupational and social impairment is not demonstrated, as some social ability is indicated by the Veteran's involvement, however strained, with his family, and with a few friends with whom he visits. In other words, while the Veteran's psychiatric impairment has clearly worsened, at no point since September 16, 2011 have the type and severity of Veteran's s psychiatric symptoms been shown to rise to the level of total occupational and social impairment required for assignment of a 100 percent disability rating . Also, pursuant to the DSM-IV, the assigned GAF score of 40 is indicative of impairment in reality testing or major impairment in several areas. The Board finds that the Veteran's GAF score of 40 is consistent with the level of impairment contemplated in the 70 percent disability rating. Accordingly, the Board finds that a 70 percent, but no higher, rating for PTSD, for the period from September 16, 2011, is warranted. In reaching this conclusion, the Board has favorably applied the benefit-of-the-doubt doctrine, but finds that the preponderance of the evidence is against assignment of the maximum, 100 percent rating. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. 49, at 53-56. C. Additional Considerations The Board finds that at no point prior to or from September 16, 2011 was the Veteran's PTSD shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. 38 C.F.R. § 3.321 (cited in the May 2012 supplemental SOC). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board 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 Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, 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, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (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. In this case, the Board finds that the applicable schedular criteria are adequate to rate the disability under consideration during all periods under consideration. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. Significantly, there is no medical indication or argument that the applicable criteria are otherwise inadequate to rate the disability. 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). As a final point, the Board notes that a claim for increase may also encompass a claim for a total disability rating based on individual unemployability (TDIU). See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the record reflects that the Veteran has been awarded a TDIU from December 16, 2010. Here, there is no indication that, pertinent to the September 3, 200p claim for increase, a TDIU due to PTSD was warranted at any point prior to December 16, 2010. Indeed, the Veteran does not allege, and the record does not reflect that, during this timeframe, the Veteran was unemployable due to his service-connected PTSD. As such, a TDIU due to PTSD for the limited period from September 2, 2009 through December 15, 2010 has not been raised, and need not be addressed. ORDER A 50 percent rating for PTSD, for the period from September 3, 2009 through September 15, 2011 is granted, subject to the legal authority governing the payment of VA compensation. A 70 rating for PTSD, for the period from September 16, 2011 is granted, subject to the legal authority governing the payment of VA compensation. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs