Citation Nr: 1318447 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 11-29 900 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to a rating higher than 50 percent for posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD T. M. Gillett, Counsel INTRODUCTION The Veteran served on active duty from January 1952 to December 1954. This appeal to the Board of Veterans' Appeals (Board) is from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Although provided opportunity, the Veteran did not request a hearing before the Board. In February 2013, subsequent to the issuance of the most recent Supplemental Statement of the Case (SSOC), the Veteran submitted additional argument in support of his claim. In this argument, however, he did not present or reference evidence specifically regarding his PTSD symptoms and their severity during the rating period at issue in this appeal, instead argued that VA should consider his physical and mental impairment over the previous 50 years (so presumably dating back to his service) in making a decision on his present claim for an increased rating for his PTSD. The Board of course will address his contentions regarding the basis for the increased rating in the decision below. However, as his submission does not contain any evidence that is otherwise particularly relevant to his claim, the Board need not remand the claim to the RO as the Agency of Original Jurisdiction (AOJ) for initial consideration of this additional evidence. See 38 C.F.R. § 20.1304 (2012). Please also note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT For the entire increased-rating period under appeal, the Veteran's PTSD has not been manifested by symptoms more nearly approximating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as obsessional rituals that 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); and an inability to establish and maintain effective relationships. CONCLUSION OF LAW For the entire increased-rating period under appeal, the criteria have not been met for a rating higher than 50 percent for the PTSD. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Duties to Notify and Assist VA has duties to notify and assist the Veteran in substantiating this claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). To this end, upon receipt of a complete or substantially complete application, VA was required to inform him of any information and medical or lay evidence not of record: (1) that was necessary to substantiate this claim; (2) that VA would obtain and assist him in obtaining; and (3) that he was expected to provide. 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate or incomplete, this timing error can be effectively "cured" by providing any necessary VCAA notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC) - such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the RO sent the Veteran a November 2009 VCAA notice letter concerning his claim prior to the December 2009 rating decision adjudicating the claim, therefore, in the preferred sequence. The letter advised him to provide evidence showing his service-connected PTSD had worsened so as to, in turn, suggest his entitlement to a higher rating for this disability. In addition, the same VCAA notice letter advised him of the necessity of providing medical or lay evidence demonstrating the nature and symptoms of his PTSD, the severity and duration of its associated symptoms, and the impact of the condition and its attendant symptoms on his employment. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (holding that VCAA notice in a claim for an increased rating need not be "veteran specific", such as by referring to alternative diagnostic codes or "daily life" evidence). The Veteran therefore has received all required VCAA notice concerning this claim. Moreover, he has not alleged any prejudicial error in the content or timing of the VCAA notice he received. As explained in Shinseki v. Sanders, 129 S. Ct. 1696 (2009), as the pleading party attacking the agency's decision, he, not VA, has the evidentiary burden of proof of showing that there is a VCAA notice error in timing or content, but also, above and beyond that, showing how it is unduly prejudicial, meaning outcome determinative of his claim. Thus, absent this pleading or showing, the duty to notify has been satisfied. VA also fulfilled its duty to assist him with this claim by obtaining all potentially relevant evidence, which is obtainable, and, therefore, appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). To this end, the RO obtained his private medical records and VA outpatient treatment records. In a May 2012 lay statement, he indicated that he had gone to a private psychologist for treatment approximately 55 years earlier, but he added that he could not recall the name or contact information for that private examiner, although he hoped that a copy of the treatment record already was in the claims file. The record on appeal does not contain any private treatment records indicating treatment for a psychiatric disorder during the 1950s or thereabouts, so from the time alleged. But inasmuch as the Veteran readily admitted he could not provide any contact information for the private examiner that treated him during those times in years past, there necessarily is no reasonable possibility of obtaining those records, even on the chance they still exist. 38 C.F.R. § 3.159(c)(1). Moreover, in claims for increased ratings, such as the one before the Board, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Specifically, in this instance, the Board is to assign a rating for the severity of the Veteran's PTSD dating back to approximately one year prior to the filing of his October 2009 claim for an increased rating. See 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). Only back to that point, not prior, is the relevant temporal focus of the status of his disability. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Therefore, the Board finds that a remand to try and procure the decades-old treatment record he mentioned in his May 2012 lay statement would serve no useful purpose and would result in unnecessarily imposing additional burdens on VA with no benefit flowing to him. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). As well, only if the record is inadequate or if there is a suggestion the current rating may be incorrect is there then a need for a more contemporaneous examination. 38 C.F.R. § 3.327(a) (2012). Here, VA performed multiple VA compensation examinations assessing and reassessing the severity of the Veteran's PTSD during the course of the increased-rating period under appeal, with the most recent examination in December 2012. The mere passage of time since does not, in and of itself, necessitate another examination. Cf. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (discussing this in the alternative context of a claim for service connection). The most recent VA examination is adequate as it provides the information needed to properly rate his disability in relation to the applicable rating criteria. 38 C.F.R. §§ 3.327(a), 4.2 (2012). The Board thus concludes that all the probative and available records and medical evidence have been obtained in order to make a fair determination as to this claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of this claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Therefore, the Veteran is not prejudiced as a result of the Board proceeding to the merits of this claim. II. Analysis In deciding this claim, the Board has reviewed all of the evidence in the Veteran's physical claims file and the "Virtual VA" electronic folder. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "[i]t is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, in a claim for increased rating, as already alluded to the most recent evidence is generally the most relevant, as the present level of disability is of primary concern. Francisco, 7 Vet. App. at 55. Nevertheless, 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, actually from one year prior, until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). If he does, then the rating must be "staged" to compensate him for this variance. The relevant temporal focus then is from one year before the claim for a higher rating was filed until VA makes a final decision on the claim. See 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); see also Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010) (explaining that the legislative history of 38 U.S.C.A. § 5110(b)(2) was to provide Veterans a one-year grace period for filing a claim following an increase in the severity of a service-connected disability). If it was factually ascertainable that an increase in rating was warranted during that immediately preceding year, then the effective date of the higher rating may go back to the date when this increase was shown, even if preceding the actual claim. See Harper v. Brown, 10 Vet. App. 125, 126 (1997). PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, a 50 percent evaluation is warranted where the evidence shows occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where the evidence shows 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); and an inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where the evidence shows total occupational and social impairment, with deficiencies such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. In adjudicating a claim for a higher disability rating, the VA adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. In this decision, the Board considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as mere examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has considered the symptoms indicated in the rating criteria as examples or symptoms "like or similar to" the Veteran's PTSD symptoms in determining the appropriate schedular rating assignment, and, although noting which criteria have not been met, has not required the presence of a specified quantity of symptoms in the Rating Schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) score is a scaled rating reflecting the psychological, social and occupational functioning on a hypothetical continuum of mental health-illness. Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994). See Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). A GAF of 61 to 70 is defined as "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 of 51 to 60 is defined as "[m]oderate 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)." A GAF of 41 to 50 is defined as "[s]erious 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)." A GAF Scale score of 31 to 40 indicates some impairment in reality testing or communication (e.g.., speech is at times illogical, obscure, or irrelevant), or a major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed person avoids friends, neglects family, and is unable to work). DSM-IV, at 32; Richard v. Brown, 9 Vet. App. 266, 267 (1996). The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. 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. The GAF score must be considered in light of the actual symptoms of a Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The Veteran essentially contends that his service-connected PTSD during the entire increased-rating period has involved symptoms more severe than contemplated by his existing 50 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411. In addition, he has requested that VA consider his entire history of PTSD, to include the period prior to the increased-rating period in making its determination. But after reviewing all of the relevant evidence of record, both lay and medical as it reflects upon the entire increased-rating period, the Board finds that the Veteran's PTSD symptomatology has not more nearly approximated the criteria required for a rating higher than the 50 percent rating assigned under Diagnostic Code 9411. Specifically, for the entire increased-rating period, the Board finds that his PTSD has not been manifested by symptoms more nearly approximating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships, as required for the next higher 70 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. Reviewing the evidence, in a November 2008 VA treatment record, a VA examiner noted the Veteran was appropriately dressed, was alert and fully oriented, made appropriate eye contact, and was appropriate in his interactions. The VA examiner noted that Veteran's speech was of normal rate, volume, and prosody, and that the Veteran's language was goal-directed. The VA examiner indicated the Veteran's mood was euthymic and that his affect was mood-congruent. The VA examiner reported finding no evidence of delusions or hallucinations. The VA examiner judged the Veteran's memory to be intact, and his insight and judgment to be good. The VA examiner diagnosed PTSD. In an additional November 2008 VA treatment record, the Veteran reported having developed a physical reaction to stressful memories and indicated that he was plagued by automatic negative thoughts. The VA examiner noted that the Veteran was appropriately dressed, and was alert and fully oriented. The VA examiner indicated that the Veteran's eye contact was poor, but also noted that the Veteran was appropriate in his interactions. The VA examiner reported that the Veteran's speech was of normal rate, volume, and prosody, and that the Veteran's language was goal-directed. The VA examiner indicated that the Veteran's mood was melancholic and his affect was blunted. The VA examiner reported finding no evidence of delusions or hallucinations. The VA examiner judged the Veteran's memory to be intact, and his insight and judgment to be good. The VA examiner indicated that there was no evidence of homicidal/suicidal ideation, intent, or plan. The VA examiner also reported that the Veteran's motor skills appeared to be within normal limits. The VA examiner diagnosed PTSD. In another November 2008 VA treatment record, a VA examiner noted similar observations to those in the most recent VA treatment record, except for findings of a euthymic mood with a congruent affect, and appropriate eye contact. In a January 2009 VA treatment record, the Veteran reported experiencing myclonic type jerks, occurring in both arms, over the previous three years. The Veteran also indicated that he experienced involuntary utterances, specifically curses, which were worse when tired or stressed. The Veteran stated that he experienced occasional depression and constant anxiety. The VA examiner noted that the Veteran's mood was stable and his thought content was adequate. The VA examiner also reported no psychotic process, hopelessness, or suicidal/homicidal ideation. The VA examiner noted that the Veteran had PTSD and assigned a GAF score of 60. In an additional January 2009 VA treatment record, the Veteran reported feeling less anxiety. The VA examiner noted that the Veteran was appropriately dressed, and was alert and fully oriented. The VA examiner indicated that the Veteran's eye contact and social interactions were appropriate. The VA examiner noted that the Veteran's speech was of normal rate, volume, and prosody, and that the Veteran's language was goal-directed. The VA examiner indicated that the Veteran's mood was euthymic and his affect was mood-appropriate. The VA examiner reported finding no evidence of delusions or hallucinations. The VA examiner judged the Veteran's memory to be intact, and his insight and judgment to be good. The VA examiner indicated that there was no evidence of homicidal/suicidal ideation, intent, or plan. The VA examiner also reported that the Veteran's motor skills appeared to be within normal limits. The VA examiner diagnosed PTSD. In an August 2009 VA social work assessment, a VA examiner noted that the Veteran had been married for 52 years and reported having a good relationship with his wife. The Veteran indicated that he had five children of whom he was very proud. The Veteran indicated that he used to drink socially, but did not do so anymore. The Veteran stated that that he still had nightmares about his stressful in-service experiences and that he had an exaggerated startle response. The Veteran stated that he currently avoided crowds and physical contact. The Veteran also indicated that he was bothered by recent memory loss. The VA social worker noted that the Veteran was a warm and friendly man, but that the Veteran had reported having a "short fuse." The Veteran stated that he had few social friends outside of his family, and that he had few other contacts. In a November 2009 VA psychiatric examination report, the Veteran reported experiencing increased dysphoria and crying spells. The Veteran stated that he felt morose and reported that, as much as he liked to help people, he did not enjoy being around them as much. The Veteran reported having a decreased interest in activities he once found pleasurable, such as watching sports. The Veteran also indicated having difficulty with his short-term memory and stated that he had begun to shout curse words, particularly while driving. The Veteran stated that he would get behind the wheel of the car and suddenly shout out a curse word, even though he usually would never say such things. The Veteran also indicated that he had physical jerky moves, described as "tics," that had not occurred previously. The Veteran reported being married to his spouse of 53 years and stated that his spouse was very supportive of him, despite all the concerns which he had caused her. The Veteran indicated that he had five children and that he continued to socialize with them when he was able. The Veteran described his family as being "tight-knit." The Veteran reported having a somewhat limited social support system outside of his family. The Veteran stated that he played the piano and took lessons regularly, gardened, and enjoyed time with his family. The Veteran indicated that he did not have a history of suicide attempts or violence. The Veteran reported having no present difficulties with alcohol or drug abuse. Upon examination, the November 2009 VA examiner noted that the Veteran was appropriately dressed. The VA examiner indicated that the Veteran's psychomotor activity was hyperactive, restless, and tense, and that the Veteran's speech was rapid. The VA examiner reported that, though the Veteran's attitude was cooperative and friendly, his affect was restricted and his mood was anxious. The VA examiner indicated that the Veteran's attention was intact, his orientation was normal, his thought process/content were unremarkable, and his judgment was normal. The VA examiner reported that the Veteran had no delusions. The VA examiner indicated that the Veteran had difficulty sleeping, waking up in the middle of the night and being unable to sleep until the next evening. The VA examiner noted that the Veteran interpreted proverbs appropriately, did not have any obsessive/ritualistic behavior, and did not have panic attacks or homicidal ideation. The VA examiner reported that the Veteran experienced occasional suicidal ideation, but also noted that the Veteran had indicated that he would never attempt to act on any ideation due to his religious beliefs. The VA examiner noted that the Veteran's impulse control was fair. The VA examiner reported that the Veteran's memory was normal upon testing, but also noted that the Veteran reported instances during which he was forgetful (i.e., leaving the car door open and walking away on a regular basis). In describing the Veteran's PTSD symptomatology, the November 2009 VA examiner noted that the Veteran had recurrent and intrusive recollections about the events during the Korean conflict, intense psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the traumatic events, and physiological reactivity on exposure to internal or external cues that symbolized or resembled an aspect of the traumatic events. The VA examiner indicated that the Veteran tended to avoid thoughts, places, people, or activities associated with the traumatic events. The VA examiner also noted that the Veteran had a markedly diminished interest in participation in significant activities and a restricted range of affect (e.g., unable to have loving feelings). The VA examiner also reported that the Veteran had difficulty falling or staying asleep, difficulty concentrating, and hypervigilance. The VA examiner noted that the Veteran's PTSD symptomatology was chronic, and mild to moderate in intensity. The VA examiner noted the Veteran had retired in 2002 because of his age and duration of work, so not on account of impairment attributable to his PTSD. After the examination, the November 2009 VA examiner diagnosed (Axis I) PTSD, tic disorder NOS, (Axis III) multiple medical problems, (Axis IV) mild problems related to the social environment, and (Axis V) GAF score of 54. The VA examiner noted that the Veteran did not have total social and occupational impairment related to PTSD. The VA examiner indicated that the PTSD symptomatology affected the Veteran's thinking, due to intrusive recollections of stressful events, difficulty concentrating during periods of distress, and possible short-term memory deficits. The VA examiner also noted that the Veteran's PTSD symptomatology affected the Veteran's mood, resulting in dsyphoria and fleeting suicidal ideation (without intent). The VA examiner reported that the Veteran had reduced reliability and productivity related to PTSD symptomatology. In a January 2010 statement, the Veteran reported being able to sleep only three hours per night. The Veteran wrote that he failed to understand why his 50-year history of PTSD symptomatology, which he had endured without assistance, was not given any consideration in assigning his disability rating. The Veteran reported that his spouse had helped him to overcome some of his symptomatology, such as drinking, related to his PTSD. The Veteran indicated that he believed that some of his efforts to overcome his symptomatology were used against him in his claim. In a July 2010 VA treatment record, the Veteran reported that he believed that his experiences during service had "messed up" his life. The Veteran indicated that his PTSD symptomatology had a significant and negative impact on his ability to earn a living. Specifically, the Veteran stated that his symptoms of hyperirritability, explosiveness, and self-isolation interfered with obtaining and holding a job. The Veteran indicated that, while working, he would be very irritable, impatient with others, emotionally disconnected, and would sometimes erupt with anger. The Veteran stated that his symptomatology caused difficulty with co-workers socially and with promotions. The Veteran recalled that, when he was denied promotions due to his symptomatology, he would become even more angry and resentful. The Veteran stated that he dealt with his PTSD symptomatology with drinking which caused more problems at home and on the job. The Veteran indicated that he had stopped drinking 15 years prior to the interview. The Veteran stated that he had met another veteran who was being provided with large disability payments for sleep apnea while the Veteran's appeal for an increased rating for PTSD had been denied. The July 2010 VA examiner noted that the Veteran appeared sad, depressed, angry, resentful, and detached. The VA examiner wrote that the Veteran appeared to have an impaired interest in life. The VA examiner noted that the Veteran had fleeting suicidal ideation, but that he was deterred from taking action due to family concerns. The VA examiner indicated that the Veteran was fairly stable clinically. The VA examiner reported that the Veteran's PTSD symptomatology interfered significantly with the Veteran's daily functioning. In an August 2010 VA treatment record, the Veteran mentioned having some financial difficulties related to a relative. The Veteran reported that he tried to help out his relative financially and by cutting her grass. The Veteran stated that he worked out in a gymnasium four times per week. The Veteran's wife reported that the Veteran was irritable, tended towards negative thinking, and tended to be critical of others. The Veteran stated that he had suicidal thoughts, but would dismiss them due to concerns for his wife and children. The Veteran indicated that he did not own a lethal weapon. The Veteran indicated that he tended to be distrustful of others; however, the VA examiner noted that he was not delusional. The VA examiner noted that the Veteran liked to joke, and that the Veteran and his wife appeared to be doing fine. The August 2010 VA examiner noted that the Veteran was alert and pleasant. The VA examiner indicated that the Veteran's mood, orientation, and memory were all good. The VA examiner wrote that the Veteran's speech was non-linear and often tangential, but socially appropriate. The VA examiner also reported that the Veteran's judgment and insight were fair. The VA examiner indicated that the Veteran was not anxious, that his affect was appropriate, and that nothing suggested suicidal or homicidal ideation, plan, or intent. The VA examiner noted finding no psychotic process. The VA examiner reported that the Veteran's thinking was linear. The VA examiner indicated that the Veteran had occasional nightmares, intrusive recollections, and hypervigilance related to PTSD. In a September 2010 VA psychiatric examination report, the Veteran reported having a good relationship with his family, but little social contact outside of his family. The Veteran stated that, when he was alone, he thought about his experiences in service most of the time. The Veteran reported drinking alcohol to deal with his experiences in Korea. The Veteran stated that, although he had quit drinking about 18 years prior to the examination, he felt remorse and resentment related to the family activities he missed due to what he considered to be service-related alcoholism. The Veteran indicated that he worked out four times per week, gardened, shopped for groceries, did puzzles in the newspaper, took piano lessons, and preformed mental exercises to work on his memory, including reciting the rosary in Latin. Upon examination, the September 2010 VA examiner noted that the Veteran was appropriately dressed. The VA examiner indicated that the Veteran's psychomotor activity was hyperactive, restless, and tense, and that the Veteran's speech was rapid, but coherent. The VA examiner indicated that the Veteran used humor throughout the interview to handle stressful topics. The VA examiner reported that, though the Veteran's attitude was cooperative and friendly, his affect was appropriate, and his mood was anxious, agitated, and expansive. The VA examiner indicated that the Veteran's attention was intact, his orientation was normal, his thought process/content were unremarkable, and his judgment was normal. The VA examiner reported that the Veteran had no delusions. The VA examiner indicated that the Veteran had difficulty sleeping, averaging about four hours of sleep per night. The VA examiner noted that the Veteran interpreted proverbs appropriately, did not have any obsessive/ritualistic behavior, and did not have panic attacks or homicidal ideation. The VA examiner reported that the Veteran did have occasional suicidal ideation; however, the Veteran had indicated that he would never attempt to act on any ideation due to his religious beliefs. The VA examiner noted that the Veteran's impulse control was fair. The VA examiner reported that the Veteran's memory was normal upon testing. In describing the Veteran's PTSD symptomatology, the September 2010 VA examiner noted that the Veteran had recurrent and intrusive recollections about the events during the Korean conflict, recurring distressing dreams, and intense psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the traumatic events. The VA examiner indicated that the Veteran tended to avoid thoughts, places, people, or activities associated with the traumatic events. The VA examiner also noted that the Veteran had a markedly diminished interest in participation in significant activities and a restricted range of affect (e.g., unable to have loving feelings). The VA examiner indicated that the Veteran had a feeling of detachment or estrangement from others. The VA examiner also reported that the Veteran had difficulty falling or staying asleep, irritability/outbursts of anger, difficulty concentrating, and hypervigilance. The VA examiner noted that the Veteran's PTSD symptomatology was chronic, and mild to moderate in intensity. The VA examiner indicated that the Veteran reported experiencing chronic disturbed sleep, monthly distressing dreams, a history of abusive drinking that resolved 18 years prior to examination, an overall depressed and resentful way of looking at the world, anxiety, changes in how he perceived the world since the Korean War, feelings of being devalued and lacking importance, and suicidal thoughts much of the time. In summarizing the Veteran's outlook, the September 2010 VA examiner wrote that the Veteran found the world to be a difficult place. The VA examiner indicated that the Veteran did not understand why the United States was currently doing business with Korea. The Veteran reported that the world was a different one than it was when he was a child. The Veteran indicated that he did not understand today's world and felt "left out." The Veteran stated that he did not like people, especially after seeing how greedy they are. The Veteran indicated that he believed that the behavior of others contributed to his temper. The Veteran reported being unable to understand why his VA disability rating was not higher, especially when compared with the ratings of others who went through less than he did in service. After the examination, the September 2010 VA examiner diagnosed: (Axis I) mild to moderate PTSD, depression, (Axis III) multiple medical problems, (Axis IV) financial stresses, problems related to the Veteran's perception of the world, and (Axis V) GAF score of 54. The VA examiner noted that the Veteran's depression clearly was secondary to his PTSD, and that the Veteran's drinking, which stopped 18 years ago, was also secondary to his PTSD. The VA examiner noted that the Veteran's prognosis for improvement was guarded. The VA examiner that the PTSD symptomatology did not affect the Veteran's judgment, thinking, family relationships, or occupation. In an October 2010 letter, the Veteran indicated that he wished to be granted a higher disability rating for PTSD. The Veteran wrote that, after his discharge from service, there were no individuals or organizations providing help for Korean War veterans. The Veteran indicated that there were no individuals or organizations providing any help for PTSD until after the Vietnam War. The Veteran stated that he first learned of VA treatment for PTSD about five years prior to the writing of the letter. The Veteran stated that that he was able to alleviate some of his stress over the years through the prayers and care of his spouse, and that, without her, he would still be in the midst of drunkenness and despair. The Veteran stated that he still experienced sleepless nights and, occasionally, startled awakenings. The Veteran reported experiencing anxiety over the previous five decades. The Veteran indicated that he still experienced effects of his anxiety, although on a smaller scale. Regarding his claim for an increased rating, the Veteran stated that he naively believed that VA would not reject a veteran of his advanced age, but soon learned that his age did not appear to be part of the qualifying equation. The Veteran wrote that, while he appeared to be "normal" during waking hours, he was different at night. The Veteran reported that his daytime activities, such as gardening, studying music, and doing crossword puzzles, were deliberately performed for the Veteran's peace of mind. The Veteran stated that he performed his daytime activities to keep himself mentally alert and to keep from falling into disturbing mood swings. The Veteran indicated that he always kept himself groomed and that his spouse aided him with household chores and shopping. The Veteran wrote that he had been hesitant to tell any of the respective VA examiners who wrote the VA psychiatric examination reports about the favorable accomplishments in his life, because his relaying such information might complicate his claim for a higher rating. The Veteran indicated that he often wondered why he made it home as opposed to his friends who died in Korea. The Veteran also stated that, at the September 2010 VA psychiatric examination, he was told that he would be discussing only the changes in his PTSD symptomatology that had occurred over the previous year. The Veteran stated that he was honest in providing his answers, but that doing so had not helped him in his claim for an increased rating. In a November 2010 VA treatment record, the Veteran reported experiencing a mild cognitive disorder, occasional nightmares, and restless sleeping, partially due to nocturia. The Veteran indicated that he had a positive attitude and loved his grandchildren. The Veteran reported that he, at one time, had a problem with alcohol, but that he did not have any such problems now. Upon examination, the November 2010 VA examiner noted that the Veteran was alert, oriented, cooperative, and pleasant, displaying a congruent affect. The VA examiner indicated that the Veteran's speech was relevant. The VA examiner reported that the Veteran experienced variable moods with moderate depression and anxiety. The VA examiner found no evidence of a thought disorder, and indicated that the Veteran denied any suicidal or homicidal ideation. The VA examiner noted that the Veteran's memory and concentration were adequate. The VA examiner indicated that the Veteran denied experiencing any suicidal ideation within the previous 30 days. In a February 2011 VA treatment record, the Veteran reported that he was seeking an increased disability rating for PTSD. The Veteran indicated that he slept pretty well, except when bothered by nocturia. The Veteran stated that he experienced nightmares, but not as often as he did previously. The Veteran also reported being irritable, but stated that his "fuse" was not as short as it was previously. The Veteran indicated that his appetite was intact and that his energy was good. The Veteran reported that his wife was a good source of emotional support. The Veteran indicated that he enjoyed gardening and playing the piano. The VA examiner diagnosed PTSD with secondary anxiety and depression. The VA examiner also indicated that the Veteran had a cognitive disorder related to a past cardiovascular accident. In an October 2011 lay statement, the Veteran reported that he did not believe that the respective VA examiners had reported all of the difficulties he had experienced regarding his PTSD over the previous 50 years. The Veteran stated that, after returning from service in Korea, he became moody, listless, and hysterical. The Veteran reported losing several employment opportunities due to his consumption of alcohol and wrote that he used to drive while inebriated. The Veteran stated that he first found about the treatment available for individuals with PTSD about seven years prior while talking to a fellow Korean War veteran. The Veteran recalled that the Korean War veteran told him that VA employees gave preferential treatment to Korean War veterans. The Veteran noted that the Korean War veteran was mistaken in that regard. In describing his reasons for wishing for an increased rating, the Veteran noted that his household was dealing with increased medical costs that were diminishing his small pension and Social Security payments. The Veteran stated that the reason he wanted the increased rating was so that he could keep the rating for a number of years and then have it passed on to his wife after his death. In a December 2012 VA psychiatric examination report, the Veteran reported that he still lived with his wife. The Veteran stated that he loved his wife and indicated that she was his "buddy." The Veteran reported that he was learning to speak and read Hindi. The Veteran indicated that he attempted to spend his time helping others, including helping a family with 20 adopted children. The Veteran reported speaking to his neighbors frequently and staying in touch with his children and grandchildren. The Veteran stated that he was active in church, attending services weekly. After a mental examination, the December 2012 VA examiner diagnosed (Axis I) PTSD, (Axis III) multiple medical problems, (Axis IV) financial stresses, problems related to the Veteran's perception of the world, and (Axis V) GAF score of 65. The VA examiner reported that the Veteran's PTSD would be manifested by symptomatology more nearly approximating 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. In explaining the Veteran's PTSD symptomatology, the VA examiner noted that the Veteran experienced depressed mood, anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood. The VA examiner noted that the Veteran reported having some mild symptomatology of depression and anxiety, but indicated that the symptoms were too mild to warrant separate diagnoses. The VA examiner stated that the Veteran's depression appeared to be tied to his resentment regarding the disability rating assigned for his service-connected PTSD. From this record of evidence, for the entire increased rating period under appeal, the Board finds that the Veteran's PTSD did not meet or more nearly approximate the criteria for a next higher 70 percent initial rating under Diagnostic Code 9411. See 38 C.F.R. § 4.130. Reviewing the record for the increased rating period under appeal, the Board notes that, in various treatment records, the Veteran has reported experiencing some suicidal ideation. The Board notes that such ideation is one of the symptoms listed in the criteria for a 70 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. Moreover, in a July 2010 VA treatment record, a VA examiner wrote that the Veteran's PTSD symptomatology interfered significantly with his daily functioning. The Board notes that such a finding, if prevalent throughout the record, would be evidence of a PTSD condition meeting or merely approximating the criteria for a higher rating than the currently assigned 50 percent rating which indicates moderate symptomatology. However, for the entire increased rating period under appeal, the Board notes that the other treatment records indicated that the Veteran's PTSD symptomatology more nearly approximated that of mild to moderate psychiatric symptomatology. In fact, in an August 2010 VA treatment record, written soon after the above-mentioned July 2010 VA treatment record, a VA examiner specifically noted that the Veteran and his wife appeared to be doing fine. Although VA examiners throughout the increased rating period on appeal noted that the Veteran experienced mild to moderate depression related to his PTSD, the same examiners did not find that the Veteran experienced near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, part of the criteria required for a 70 percent rating. See id. In the July 2010 VA treatment record, the Veteran reported difficulties he experienced during his periods of employment. The Veteran stated that he was often irritable, angry, and impatient with co-workers, and reported being passed up for promotions due to his behavior. The Veteran attributed his anger and irritability to his service-connected PTSD. The Board notes that such symptomatology would more nearly approximate difficulty in adapting to stressful circumstances (including work or a worklike setting), part of the criteria for a next higher 70 percent rating. See id. Yet, the Board notes that the evidence of record indicates that the Veteran is retired and has been so for many years. During the increased rating period under appeal, the Veteran reported experiencing instances when he would begin involuntary utterances, specifically curses, which were worse when tired or stressed (such as while driving). While the Veteran's cursing is suggestive of some degree of impaired impulse control, such behavior does not more nearly approximate the large degree of impaired impulse control, usually involving unprovoked irritability with periods of violence, contemplated in the criteria for the next higher 70 percent rating. See id. Moreover, except for the noted cursing during periods of stress, for the increased rating period under appeal, the evidence does not indicate other instances of difficulty in adapting to stressful circumstances, mostly due to the Veteran's possibly intentional avoidance of such circumstances. Therefore, the evidence of record for the increased rating period under appeal indicates that the Veteran's PSTD symptomatology has not more nearly approximated difficulty in adapting to stressful circumstances (including work or a worklike setting). See id. In addition, in an August 2010 VA treatment record, a VA examiner noted that the Veteran's speech was non-linear and often tangential, but socially appropriate. During the entire increased rating period under appeal, the record contains no finding indicating that the Veteran's speech more nearly approximated the intermittently illogical, obscure, or irrelevant speech, contemplated in the criteria for the next higher 70 percent rating. See id. Moreover, during the entire increased rating period under appeal, the record contains no notation indicating that the Veteran's PTSD was manifested by obsessional rituals which interfered with the Veteran's routine activities; spatial disorientation; or neglect of his personal appearance and hygiene, as contemplated in the criteria for the next higher 70 percent rating. See id. Moreover, the Board notes that, although the Veteran noted having a small social network outside of his family, the evidence of record consistently shows that the Veteran has maintained a stable and strong relationship with his family members, especially his spouse. Such evidence weighs against a finding of an inability to establish and maintain effective relationships, another of the criteria for a 70 percent rating. See id. Reviewing the GAF scores for the increased rating period under appeal, the Board notes a variance in the GAF scores assigned by the respective VA examiners. The Board notes that the GAF scores have varied with the highest GAF score, assigned in a December 2012 VA psychiatric examination report, being 65, and the lowest, assigned in respective November 2009 and September 2010 VA treatment records, being 54. The Board notes that a GAF score of 54, the lowest assigned during the initial rating period, is considered to be consistent with moderate occupational and social impairment with reduced reliability and productivity, consistent with the currently assigned 50 percent rating. Therefore, for the increased rating period under appeal, the GAF scores assigned are not indicative of symptoms more nearly approximating the criteria for a next higher 70 percent rating under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The Board notes that the Veteran has expressed frustration with the manner in which VA has evaluated his claim. Specifically, the Veteran has stated that VA has not taken into account his nearly 50 years of PTSD symptomatology. The record clearly suggests that the Veteran experienced a long history of alcoholism related to his PTSD. However, the evidence suggests that the Veteran's alcoholism over a decade prior to his claim for VA benefits. As noted above, in claims for an increased ratings, the rating is to be based on the current manifestation of the Veteran's PTSD symptomatology. While VA acknowledges the Veteran's service and the difficulty he went through over the years, VA, by statute and regulation, is to base the Veteran's rating on the symptomatology experienced during the increased rating period under appeal. Having reviewed the evidence of record for the entire increased rating period under appeal, the Board finds no basis for a schedular rating higher than 50 percent for the service-connected PTSD. The Veteran has not met the requirements for a higher schedular rating at any time since one year prior to filing this increased-rating claim, so the Board also cannot "stage" this rating. See Hart, 21 Vet. App. at 505 (indicating the relevant temporal focus is from one year before the claim for a higher rating was filed until VA makes a final decision on the claim). See also 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). And since, for the reasons and bases discussed, the preponderance of the evidence is against the claim, the benefit of the doubt rule is inapplicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In considering this claim for a higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors that would render application of this schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The question of an extra-schedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). And although the Board may not assign an extra-schedular rating in the first instance, it must specifically adjudicate whether to refer a case for extra-schedular evaluation when the issue either is raised by the claimant or reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran'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." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension (C&P) Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). Here, the symptoms associated with the Veteran's service-connected PTSD are not shown to cause any impairment that is not already contemplated by the relevant diagnostic codes, so the Board finds that the rating criteria reasonably describe his disability. The symptoms noted during the increased rating period under appeal (flattened affect, some memory loss, sleep impairment, disturbances of motivation and mood) are those specifically contemplated by the schedular rating criteria. Weighing the evidence in the Veteran's favor, the symptomatology more nearly approximates that contemplated by the 50 percent rating currently assigned under 38 C.F.R. § 4.130, Diagnostic Code 9411. As such, the schedular evaluation contemplates his level of PTSD symptomatology and the Board need not determine whether there is an exceptional disability picture exhibiting other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1). Accordingly, referral for consideration of an extraschedular rating is unwarranted. See Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). ORDER The claim of entitlement to a rating higher than 50 percent for the PTSD is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs