Citation Nr: 1317656 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 03-09 465 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an initial evaluation for posttraumatic stress disorder (PTSD), evaluated as 10 disabling prior to September 29, 2009; a 50 percent evaluation from September 29, 2009 to May 18, 2012; and a 70 percent evaluation since May 19, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD William J. Jefferson III, Counsel INTRODUCTION The Veteran had active service from June 1964 to June 1966. He also had Army Reserve and Army National Guard service, including a period of active duty for training (ACDUTRA) from June 18, 1977 to July 2, 1977. This case comes to the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. A rating decision in January 2003 granted service connection for PTSD, evaluated as 10 percent disabling effective from September 16, 2002. The RO also determined that new and material evidence had not been received to reopen the claim of service connection for vertigo. In September 2005, the Veteran presented oral testimony at a videoconference hearing held before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer who chairs a hearing fully explain the issues and suggest the submission of evidence that may have been overlooked. At the hearing the undersigned acting Veterans Law Judge, identified the issue on appeal and solicited the Veteran to identify evidence relevant to the claim. The Veteran reported his service and medical history, and he described his symptoms associated with his claimed conditions. The Board finds that the hearing did not reveal any other evidence that might be available, but has not been associated with the claims file. The Veteran has not alleged that there were any deficiencies in the hearings related to the hearing officer's duties under section 3.103(c)(2). See Bryant, 23 Vet. App. at 497-98. In a decision/remand dated in November 2005, the Board determined that the Veteran had filed a timely notice of disagreement with a January 2002 rating decision which denied service connection for vertigo, and, hence, the issue must be considered on the merits. The Board also found that the issue of a higher rating for PTSD, on appeal at the time service connection was severed in November 2004, remained pending after the June 2005 rating decision restoring service connection. The issues were then remanded for additional development. In July 2009, these issues were again remanded by the Board. In a July 2010 rating decision, the AOJ issued assigned an increased rating of 50 percent for PTSD, effective September 29, 2009. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a Veteran appeals his initial rating, VA must consider whether to "stage" the rating to compensate him for times since the effective date of his award when the disability may have been more severe than at others). In April 2011, the Board remanded the issues for more development. In a September 2012 rating decision, the Appeals Management Center (AMC), granted the claim of service connection for vertigo, and the Veteran's 50 percent disability evaluation for PTSD was increased to70 percent disabling effective from May 19, 2012. As a result, the issue of service connection for vertigo is no longer on appeal before the Board. FINDINGS OF FACT 1. From September 16, 2002 to May 18, 2012, (including from September 16, 2002 to September 28, 2009), the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms; but the higher rating requiring occupational and social impairment, with deficiencies in most areas, is not shown during this period. 2. Since May 19, 2012 the Veteran's PTSD is not manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for an initial rating of no more than 50 percent for PTSD, for the period from September 16, 2002 to September 28, 2009 have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.126, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The criteria for an initial rating in excess of 50 percent for PTSD from September 29, 2009 to May 18, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.126, 4.130, Diagnostic Code (DC) 9411 (2012). 3. The criteria for an initial rating greater than 70 percent for PTSD since May 19, 2012 have not been. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.126, 4.130, DC 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. See Gonzales, 218 F.3d at 1380-81. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Id. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. I. Duties to Notify and Assist The Veterans Claims Assistance Act (VCAA) provides that VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of what is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). The VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). All notice under the VCAA should be provided prior to an initial decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). However, the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See 38 U.S.C. § 5103(a) (West 2002). Compliance with the first Quartuccio element requires notice of these five elements. See id. at 486. The VCAA further provides that VA has a duty to assist the veteran in the development of the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). This duty includes assisting him in obtaining service treatment records and other pertinent treatment records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See id. The Board finds that the duty to notify has been satisfied. A VCAA notice letter was sent in August 2001 which informed the Veteran as to each element of satisfactory notice set forth under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Also where the increased-rating claim arose in another context, namely, the Veteran trying to establish his underlying entitlement to service connection, and the claims since have been granted and he has appealed these "downstream" issue concerning the initial rating and effective date assigned for his disability, the underlying claim has been more than substantiated, it has been proven, thereby rendering § 5103(a) notice no longer required because the initial intended purpose of the notice has been served. See Goodwin v. Peake, 22 Vet. App. 128 (2008). Thereafter, once a notice of disagreement (NOD) has been filed contesting the "downstream" issue of the initial rating assigned for the disability, the notice requirements of 38 U.S.C. §§ 5104 and 7105 regarding a rating decision and SOC control as to the further communications with him, including as to what evidence is necessary to establish a more favorable decision with respect to this downstream elements of the claims. Id.; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) and VAOPGCPREC 8-2003 (Dec. 22, 2003). And he received this required most recently in July 2010 and September 2012 SSOCs discussing his downstream claims for a higher initial rating and earlier effective date, citing the applicable statutes and regulations, and providing reasons and bases for not assigning a higher. He was informed him of the evidence required to substantiate the claim and of his and VA's respective responsibilities in obtaining this supporting evidence, as well as the "downstream" disability rating and effective date elements of his claims. Thus, no further notice is required. See Goodwin v. Peake, 22 Vet. App. 128 (2008) and Huston v. Principi, 17 Vet. App. 195 (2003). The Board also concludes that the duty to assist has also been satisfied. The Veteran's service treatment records (STRs) and post-service medical records have been associated with the claims file. The Veteran has not identified any other outstanding records that he wanted VA to obtain or that he felt were relevant to the present claim. The Veteran has also been afforded VA examinations, most recently in May 2012 for information and for evaluation of his PTSD disability The Board finds the examination reports to be adequate for adjudication on the merits. See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). Finally, the Board finds that there has been substantial compliance with its April 2011 remand directive. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran was afforded a VA compensation examination which was conducted in accordance with the Board's directives. In sum, the record reflects that the facts pertinent to the claim have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. That is to say, "the record has been fully developed," and it is "difficult to discern what additional guidance VA could [provide] to the appellant regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F. 3d. 1369 (Fed. Cir. 2004). Accordingly, the Board will adjudicate the claim on the merits. II. Increased Ratings Initially, it is important to point out that where a Veteran appeals the rating initially assigned for a disability, after already having established service connection for it, VA must consider the propriety of a staged rating that is indicative of changes in the severity of the course of her disability over time. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court recognized a distinction between a veteran's dissatisfaction with an initial rating assigned following a grant of service connection and a claim for an increased rating of a service-connected disorder. In the case of the assignment of an initial rating for a disability following an initial award of service connection for that disability (the circumstances of the present appeal), separate ratings can be assigned for separate periods of time based on the facts found - "staged" ratings. See Fenderson, supra, at 125-26. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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 (2012). As discussed in the above Introduction, the Veteran was granted service connection for PTSD in a January 2003 decision and assigned a 10 percent disability rating, effective from September 16, 2002. He appealed this initial disability rating, and then his rating was severed, but later it was restored not affecting his claim for an increase as far as disposition of the claim here. In a July 2010 rating decision, the AOJ assigned an increased rating of 50 percent for PTSD, effective September 29, 2009. Then in September 2012, subsequent to a Board remand, the AMC, the Veteran's PTSD was increased to70 percent disabling effective from May 19, 2012. The Veteran's disability evaluation has therefore already been staged and each rating will be discussed separately. See Fenderson, supra. The Veteran's PTSD is evaluated pursuant to 38 C.F.R. § 4.130, DC 9411 (2012). Under DC 9411, the criteria for a 10 percent rating are occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. The criteria for the next higher rating, 30 percent, are 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). Id. The criteria for a 50 percent rating are occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id The criteria for a 70 percent rating are occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id A 100 percent rating requires 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 of names of close relatives, own occupation or own name. Id. The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health- illness." DSM-IV at 32. GAF scores ranging from 61 to 70, for example, reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). See Carpenter v. Brown 8 Vet. App. 240, 242 (1995). III. An Initial Evaluation for PTSD, Evaluated as 10 Disabling Prior to September 29, 2009; and a 50 Percent Evaluation from September 29, 2009 to May 18, 2012 The Veteran was awarded a 10 percent rating for PTSD from September 16, 2002 until September 28, 2009, and then a 50 percent rating from September 29, 2002 until May 18, 2009. He asserts the assigned ratings are inadequate and should be increased. VA outpatient mental health records from mid to late 2002 through May 2004 show that the Veteran received treatment for psychiatric problems, with symptoms including depression, and auditory hallucinations. He was oriented to time and place during this time. Major depression and PTSD were diagnosed, and it was reported that the Veteran had been prescribed psychotropic medication. In a February 2003 mental health entry, it was reported that the Veteran's GAF score was 50. VA treatment records in early 2004 show the Veteran was noted to have PTSD and depression. He had intrusive memories and poor concentration and continued auditory hallucinations. In March 2004 a clinical entry reported that the Veteran's GAF was 63, and psychosis was diagnosed. In June 2004 a GAF of 46 was reported. By late 2004 VA records show the Veteran continued with PTSD symptoms, including nightmares, poor sleep, irritability, social isolation, flashbacks, depression, and hallucinations. In January 2005, the Veteran's GAF was 40, and the diagnoses were: PTSD, and depression with psychotic features. In a May 2005 VA PTSD examination, it was reported that the Veteran had nightmare of accidents one to two times per week. He had auditory hallucinations, anxiety around crowds, daily intrusive thoughts, and problems controlling his irritability and anger. The Veteran lived with his mother. He reportedly was capable of performing activities of daily living and he performed them routinely. The Veteran reported that he last worked in 1989, and that he stopped working due to orthopedic problems and his psychiatric difficulties. The mental status examination showed that the Veteran was alert and oriented. His orientation was normal. He was able to provide an accurate history. His affect was blunted. Speech was spontaneous and fluent. His memory was normal. He was logical and goal oriented. There was mild dysphoria, intermittent feelings of hopelessness and helplessness. He denied suicidal or homicidal ideation or plan. There was no evidence of thought disorder. The diagnoses were: PTSD and major depression. The GAF score was 58. It was mentioned that his overall PTSD and depression resulted in mild social and occupational impairment. At a January 2007 VA PTSD examination, the Veteran reported daily panic attacks, irritability, sleep difficulty, intrusive thoughts and nightmares of a 1964 automobile accident. His medications included Trazadone, Clonazepam, and Quetiapine. He presented adequately dressed and groomed. His speech was clear and coherent. He was oriented. There was some impairment of his concentration and short term memory. There was no thought disorder. His thought process was linear and devoid of delusional content. His affect was blunted, and his mood was dysphoric. The diagnosis was: PTSD. The GAF score was 45. VA treatment records through late 2009 report a diagnosis of dementia. It was reported that the Veteran continued with psychological symptoms, and he attended group therapy. In October 2009 a VA PTSD examination as conducted. The Veteran reported panic attacks and depression. He was moody, became angry, and he did not like talking to anyone. He denied frank flashbacks, and said that he heard voices telling his to kill himself. He indicated that they (auditory hallucinations) were adequately treated with medication. The Veteran reported intrusive thoughts several times per week. He reported that he had three friends. He also had startle response. It was stated that he had to stop working because of multiple orthopedic problems. The mental status examination showed that the Veteran was alert and oriented. He provided an accurate history. His insight was not well demonstrated. His affect was blunted. He had spontaneous fluent speech. His memory was grossly normal with difficulty with details. There was cognitive impairment on testing. There was no disorder of thought processes. The diagnoses were: PTSD, chronic, moderate; cognitive disorder, not otherwise specified. The GAF was 55. The examiner stated that the Veteran had PTSD related to his accident in service. It was also mentioned that the Veteran's overall disability was moderate. Analysis The Board has considered the entirety of the evidence and concludes that for the entire period from September 16, 2002 to May 18, 2012, (including from September 16, 2002 to September 29, 2009), a 50 rating for PTSD is demonstrated, but not higher. In other words, an increased initial rating is warranted from 10 to 50 percent from September 15, 2009 to September 28, 2009; and thereafter, no more than a 50 percent rating is warranted until May 19, 2012. VA records from late 2002 going forward, show that the Veteran received treatment for psychiatric symptoms, including depression, anxiety, intrusive thoughts, sleep disturbance, flashbacks, as well as auditory hallucinations. The Veteran also had some problems with concentration and on an occasion impairment of short-term memory. The Veteran was isolative at times, but he had lived with his mother, and it was later reported that he had three friends. He reportedly had not worked since 1989 due to orthopedic problems, reported as recently as October 2009. The Veteran has received treatment with psychotropic medication and group therapy during this time, albeit with continued symptomatology. As mentioned before though, these same symptoms and medical history were reported in VA records from late 2002 through late 2009. It is noted that in addition to PTSD, depression and dementia were diagnosed during the time frame. However, during the period in question, the VA clinicians characterized the severity of the Veteran's service-connected PTSD, alone, as being mild or moderate. Although the Veteran's GAF scores for his psychiatric disorder, including PTSD, ranged from 40 through 63, they were predominantly in the 50s. It is acknowledged that 40 is at the high range for the particular GAF category, but considering the overall scores, it is apparent that the Veteran's overall condition is more reflective of moderate to serious symptoms. As a result, the Board concludes that from September 16, 2002 to September 28, 2009, the criteria for no more than a 50 percent disability rating for PTSD, 38 C.F.R. § 4.130, Diagnostic Code 9411, have been demonstrated by the medical evidence. As of September 29, 2009 to May 18, 2012, no more than the assigned 50 percent rating is proper. The medical evidence shows that on mental status examination, the Veteran was oriented, and it was reported that he presented clean and groomed. Suicidal ideations were reported, yet there were no subsequent reports of this behavior, most notably not in October 2009. While there were obvious and substantial psychological manifestations during this time, there is no indication that he had occupational and social impairment, with deficiencies in most areas that equate to a 70 percent rating for PTSD, under DC 9411. After considering the totality of the evidence of record from the entire period September 16, 2002 to September 28, 2009, and from September 29, 2009 to May 18, 2012, the Board finds the Veteran's PTSD is no more than 50 percent disabling under 38 C.F.R. § 4.130, DC 9411. At no point during that time did the Veteran's PTSD warrant a 70 percent rating. The Board has considered the statements and testimony from the Veteran, as well as his representatives' arguments. This lay testimony is probative, in conjunction with the other evidence of record, particularly the objective medical evidence, in determining the PTSD symptoms and resulting occupational and social impairment. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). III. A 70 Percent Evaluation for PTSD since May 19, 2012 In a September 2012 rating decision, the RO assigned a 70 percent rating for the Veteran's PTSD, effective May 19, 2012. In May 2012, a VA PTSD examination was performed. The Veteran lived alone since his mother had passed away. He was reportedly disabled due to PTSD and chronic back pain. He continued with mental health treatment, including medicines. It was reported that the Veteran had difficulty with insomnia and panic attacks. He also had recurrent and distressing recollections, recurrent distressing dreams, and flashbacks. He also had symptoms of physiological reactivity on exposure to internal or external cues, persistent avoidance of stimuli, and persistent symptoms of increased arousal. The symptoms lasted for more than a month, and caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Veteran's symptoms also included depressed mood, anxiety, panic attacks, mild memory loss, flattened affect, and disturbance of motivation and mood. The diagnosis was PTSD. The GAF score was 50. The Board of two examiners opined that the PTSD symptoms were related to a car accident that occurred during his active duty. The Board has reviewed the evidentiary data and concludes that since May 19, 2012, a rating in excess of 70 percent for the Veteran's PTSD is not demonstrated. At this recent May 2012 VA examination, there were no psychotic manifestations reported, nor was there any indication that the Veteran was neglectful of his personal appearance and hygiene. His PTSD symptoms included intrusive memories, nightmares, flashbacks, avoidance, and increased arousal. His social functioning shows isolative behavior without mention in the recent examination of any relationships, he lives alone since his mother passed away. The examiners also indicated that the Veteran's GAF score was 50. GAF Scores 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). His occupational adaptability had remained static; in the past he reported he had not worked due to (non-service connected) orthopedic problems. The Veteran's PTSD is not shown to be manifested by the symptoms consistent with a maximum 100 percent rating under Diagnostic Code 9411, such as grossly impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for basic concepts such as names of close relatives, or for the Veteran's own occupation or name. Therefore, the assigned 70 percent rating from May 19, 2012, 2009 is adequate. The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences, he is competent to report that he experiences certain symptoms. The Board finds the Veteran to be credible in his reports of the symptoms he experiences. However, as with the medical evidence of record, the Veteran's account of his symptomatology is consistent with the assigned rating. See Jandreau and Buchanan, supra. Therefore, and for reasons and bases set forth above, the preponderance of the evidence is against the claim for a rating in excess of 70 percent for PTSD from May 19, 20129, and for purposes of an increased rating during this time, the benefit-of-the-doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Extraschedular Consideration The Board finds that at no point since the date of the claim has the PTSD disability been shown to be so exceptional or unusual as to warrant the assignment of a rating higher than 50 percent from September 16, 2002 to May 18, 2012, (including from September 16, 2002 to September 29, 2009); and 70 percent from May 19, 2012, on an extraschedular basis. See 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular 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 Procedural 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 extraschedular 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 the Board 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 extraschedular rating. Thun, supra. In this case, the Board finds that the schedular criteria are adequate to rate the Veteran's PTSD disability. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than those assigned based on more significant functional impairment. 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 50 percent rating from September 16, 2002 to September 28, 2009 is granted for PTSD subject to the statutes and regulations governing the payment of VA compensation. An initial rating greater than 50 percent from September 29, 2009, to May 18, 2012, for PTSD is denied. An initial rating greater than 70 percent for PTSD as of May 19, 2012 is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs