Citation Nr: 1318755 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 09-37 127A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUE Entitlement to an increased disability evaluation (rating) in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is also the appellant, had active service from November 1965 to January 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Boston, Massachusetts. Thereafter, the Providence, Rhode Island, RO assumed jurisdiction. The appeal arises from the May 2007 rating determination, as subsequent to the May 2007 rating determination, treatment records from the VetCenter, which were requested prior to the May 2007 rating determination, were associated with the claims folder. As these records were pertinent to the claim they allowed the claim to remain open. 38 C.F.R. § 3.156(b) (2012); Buie v. Shinseki, 24 Vet. App. 242, 252 (2011) (stating that RO decision becomes final "only after the period for appeal has run" and that any interim submissions before finality must be considered by the VA as part of the original claim). Therefore, the Board will address this issue as though it arises from the May 2007 rating determination. As it relates to the request for an effective date earlier than July 31, 2007 for the assignment of a total rating based upon individual unemployability due to service-connected disabilities (TDIU), raised by the Veteran in his May 2011 statement in support of claim, the Board notes that, in a January 2010 rating determination, the RO granted a TDIU and assigned an effective date of July 31, 2007. The Veteran was notified of this decision, which was the grant of the full benefit sought on appeal, in February 2010. Because no further argument or evidence was received with regard to this claim within one year, the rating determination became final. In his May 2011 statement in support of claim, the Veteran requested an earlier effective date, namely July 27, 2006, be assigned for the grant of the TDIU. With regard to such requests for earlier effective date entered over one year after a rating decision assigning effective date becomes final, the Court has barred appellants from seeking to disturb the finality of a prior rating decision by attempting to file such a "freestanding" earlier effective date claim. Rudd v. Nicholson, 20 Vet. App. 296 (2006) (VA claimants may not properly file, and VA has no authority to adjudicate, a freestanding earlier-effective-date claim in an attempt to overcome the finality of an unappealed rating decision). As a result, the Board is not referring the request to the RO for further action, as it is not a valid "claim" or appeal. FINDINGS OF FACT 1. For the rating period prior to January 20, 2009, the Veteran's PTSD was not characterized by 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 interfered 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. 2. For the rating period from January 20, 2009, the Veteran's PTSD has caused occupational and social impairment with deficiencies in most areas including difficulties in the work environment, mood problems, impaired impulse control, unprovoked irritability, difficulty in adapting to stressful circumstances, an inability to establish and maintain effective relationships, near continuous depression, lack of energy/motivation, and intrusive thoughts. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 50 percent for PTSD prior to January 20, 2009 were not met or more nearly approximated. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. Resolving reasonable doubt in favor of the Veteran, the disability criteria for a 70 percent evaluation for PTSD from January 20, 2009 have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Assist and Notify The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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; (3) and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 has been amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). The Board notes that the Veteran's status has been substantiated. The Board observes that in September 2006 and October 2007 letters the RO provided the Veteran with notice that informed him of the evidence needed to substantiate his claim. The letters also told him what evidence he was responsible for obtaining and what evidence VA would undertake to obtain. The letters further told him to submit relevant evidence in his possession. The September 2006 and October 2007 letters also provided the Veteran with notice as to the disability rating and effective date elements of the claim. Although the October 2007 notice letter was not sent before the initial RO decision in this matter, the Board finds that this error was not prejudicial to the Veteran because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the Veteran been afforded a meaningful opportunity to participate effectively in the processing of his claim and been given ample time to respond, the RO has also readjudicated the case by way of a supplemental statement of the case issued after the notice was provided. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Furthermore, the Veteran and his representative have presented detailed argument which shows they are aware of what is needed to substantiate the claim. VA has a duty to assist a veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All pertinent treatment records, service, VA, and VetCenter, have been obtained and associated with the claims folder. No other relevant records have been identified. The Veteran was afforded VA examinations in March 2007, April 2008, and December 2009. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the examination reports set forth a history, assessments of social and industrial impairment, and detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examinations to be adequate for rating purposes. The examination reports provided a history supplied by the Veteran and detailed examination results. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and by being afforded the opportunity to appear at a hearing if so desired. As to the right for a hearing, the Board notes that the Veteran, in his October 2009 substantive appeal, requested that he be afforded a Travel Board hearing at the Boston RO. In May 2011, the Veteran withdrew his request for a hearing. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the 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 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. Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (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 (2007). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The General Formula for Rating Mental Disorders, Diagnostic Code 9411, provides that a 50 percent evaluation requires 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 abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned for 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. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent evaluation is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The symptoms cited above follow the phrase "such symptoms as" which indicates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the Board has not required the presence of all or most of the enumerated symptoms for any particular rating. The list of symptoms merely 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 the claimant's social and work situation. The Board must consider all symptoms of the veteran's condition which affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 441-443 (2002). The Global Assessment of Function (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM), 32 (4th ed.) (1994) (DSM IV); 38 C.F.R. §§ 4.125, 4.130 (2012). GAF scores from 71 through 80 is indicative that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more that slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). Scores ranging from 61 through 70 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, and has some meaningful interpersonal relationships. Scores ranging from 51 through 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 through 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). A GAF score of from 31 through 40 contemplates some impairment in reality testing or communication (e.g., speech 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). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Veteran maintains that an evaluation in excess of 50 percent is warranted for his PTSD. He maintains that the symptomatology associated with PTSD, including sleep problems, depression, panic symptoms, isolation, irritation, being angry, and work pressures when he worked, demonstrate that an evaluation in excess of 50 percent is warranted. In conjunction with his claim, the Veteran was afforded a VA examination in March 2007. At the time of the examination, the Veteran reported having sleep problems, symptoms of depression, and panic symptoms. The Veteran stated that he regularly visited his family. He retired at the age of 54 from the Police Department. The Veteran indicated that he worked in the licensing division, which regulated bars/saloons, but felt after 12 years he could not take the pressure from supervisors and was using too much sick time. After 14 years of employment, he retired. At the March 2007 VA examination, the Veteran stated that he had difficulty sleeping and was stirred by the war in Iraq and Afghanistan. He felt nervous, especially in crowds. He also noted often feeling irritated and angry and voiced his anger. He tended to take long walks after angry outbursts. His wife would sometimes leave the home when he became angry. The Veteran stated he could not watch TV and avoided reading the newspapers. He indicated that he was more confined in the Winter and had more flashbacks, memories, bad dreams, and anxieties during this time. He stated that when the weather improved he would go for walks, do yard work, and watch small scale sporting events. He continued to attend VetCenter meetings, as he had done for the past three years. The Veteran reported that a typical day included walking, having a few drinks, feeling fatigued, and trying to improve his sleep cycle. He saw friends weekly and talked to his kids every week. He noted having recently traveled to see his brother in Florida. He had no interest in returning to work. He had four to five alcoholic drinks per night. He reported that he had nervousness and anxiety, particularly in crowds. He also felt irritation and anger and coped by walking and withdrawing from stimulus. The Veteran reported having feelings of sadness, hopelessness, and pessimism. He also wondered about his purpose and worth. He denied suicidal thinking, plan, or intent. He reported ongoing drinking to calm himself. Mental status examination performed at the time of the March 2007 VA examination revealed the Veteran was on time and dressed in casual clothes, looking his stated age. He was alert and oriented in all spheres and had good hygiene and grooming. He did not have symptoms of psychosis and thinking was clear, logical, and goal-directed. Speech was within normal limits and cognition was intact. His weight was under control but he reported periodic stomach upsets. The March 2007 VA examiner indicated that the Veteran continued to show distressing recollections from Vietnam, had bad dreams and flashbacks, and distress from war stories from the Iraq and Afghanistan conflicts. He also avoided crowds, news stories, and situations that aroused symptoms. The examiner also noted that the Veteran often felt estranged from others and felt uncomfortable in social situations or large crowds. His drinking and anger served to keep people away and to avoid contact with others. Sleep problems, anger expressions, irritability, and problems with memory and concentration were also noted. The examiner stated that the Veteran did not appear to suffer significant social withdrawal from friends or family, but restricted his contact to those he trusted. The examiner rendered Axis I diagnoses of PTSD; R/O alcohol abuse/dependence; R/O panic disorder with agoraphobia; and R/O early signs of dementia. The examiner also assigned a GAF score of 55. In a May 2007 letter, a VA RN-CS,MSN, indicated that she had been working with the Veteran at the VetCenter since July 2004 on a weekly basis. She stated that the Veteran suffered from persistent avoidant symptoms, irritability, hypervigilance, and exaggerated arousal. He also had problems with trusting authority. It was further noted that the Veteran had problems falling and staying asleep, and was up 3-4 times per night. The War in Iraq had triggered additional flashbacks and nightmares about his Vietnam experience. It was also indicated that the Veteran had problems with anger, was easily agitated, and had a short fuse. He was bothered with problems regarding memory and concentration. His whole life since Vietnam had been one of increasing isolation and seclusion. The Veteran reported that he had problems trusting others and was apprehensive and on guard in crowds. She noted that she had been working with the Veteran in her weekly Worcester Police Group. She stated that since talking about his PTSD symptoms, the Veteran had had some improvements and some setbacks. Treatment records obtained from the VetCenter for the period covering March 2005 to May 2007 reveal that the Veteran, for the overwhelming majority of group sessions, was found to have a normal appearance, a calm affect, normally alert cognitive functioning, and to have contributed to the group discussion. At the time of an April 2008 VA examination, the Veteran indicated that he and his wife still lived in Yarmouth and that his children lived in the Worcester area. He had one child from his second marriage whom he saw weekly and was closest to her. He saw the four children from his first marriage on a less frequent basis. He had seven grandchildren whom he occasionally saw. He got along with all the grandchildren. He also got along with his wife. He preferred solitary activities, while his wife liked to socialize. When his wife became upset with him, she would go back to Worcester. She complained he was too impatient and distant. The Veteran stated he liked living in the Cape as it was quiet and he could stay by himself. He did not stay in touch with old friends or colleagues from work. He did maintain ties with the Worcester VetCenter. The Veteran stated that when he heard from a former acquaintance, he did not say much. The Veteran indicated that he liked to walk, especially when he was upset or when his wife had plans that he did not want to do. He liked to visit his brother in Florida in the Winter but his wife preferred to stay in Massachusetts closer to his daughter. He used to be an avid golfer but did not have the drive now to do so. The Veteran reported a history of suicide attempts. He reported no history of violence or assaultiveness. The Veteran stated that he tended to get easily irritated and impatient and that he preferred solitary activities and his social life was limited to his PTSD group. He indicated that even with family, there was some tension with his wife. He stated that his use of alcohol may have increased with retirement and to calm himself down. He reported drinking 6 to 8 drinks per day. The Veteran stated that he became easily depressed by a rainy day or negative news, especially casualties from the war in Iraq. He also reported that he would lose track of programs on TV and had paid a bill twice on occasion. The Veteran also indicated that he had trouble falling asleep and waking up early and that he felt like he would lie awake for hours at night. He also reported having excessive daytime drowsiness and relied upon his wife to drive. As to inappropriate behavior, the Veteran stated that loud noises would startle him causing flashbacks to Vietnam and that MRI noises reminded him of 50 caliber rounds in Vietnam. As to obsession/ritualistic behavior, the Veteran indicated that he would double check the doors and windows. The Veteran also reported having panic attacks when under stress, such when as facing his children or driving into Boston. As to episodes of violence, the Veteran reported that there were no physical episodes but indicated that he would have verbal outbursts. He reported that he would go for a walk when he had these. The Veteran stated that he was able to maintain hygiene. Mental status examination in April 2008 VA revealed the Veteran was casually dressed. Psychomotor activity was unremarkable. Speech was hesitant, soft or whispered, and coherent. His attitude toward the examiner was cooperative and friendly. His affect was constricted and depressed, dysphoric. He was also easily distracted but could do serial sevens and spell a word backwards and forwards. Thought process was unremarkable. As to thought content, the Veteran had obsessions and ruminations. He doubled checked windows and doors at night. He would also get anxiety or panic proportions at times, such as when seeing his kids after a long time for fear of their reaction to his PTSD. He also ruminated about a soldier who had grabbed his gun and had shot the Veteran in the knee. There were no delusions, and as to judgment, the Veteran understood the outcome of his behavior. His intelligence was average, and as to insight, the Veteran partially understood that he had a problem. There were no homicidal thoughts but the Veteran did have thoughts of suicide. There were no plans or intentions. Impulse control was described as fair. Remote, recent, and intermediate memory were described as slightly impaired. The VA examiner in April 2008 indicated that the Veteran's PTSD symptoms were ongoing daily and were of moderate severity. The PTSD symptoms had been progressive since the Veteran's father's death and since 9/11. The examiner rendered Axis I diagnoses of PTSD and R/O alcohol abuse. The examiner assigned a GAF score of 55. The examiner noted that the Veteran had retired in 2004 but was experiencing increased symptoms and not getting along with his supervisors and had missed work before then. It was observed that the Veteran reported having had a decline in social relationship and a decline in sleep and patience, along with an increase in PTSD symptoms, in the past year. The examiner noted that the Veteran retired in 2004 and was reporting moderately severe interference with social functioning. At the time of a January 2009 VA mental health outpatient assessment, the Veteran reported that he had been suffering from depression. He also indicated that he was not sleeping well and that he had trouble falling and staying asleep. He felt his sleep to be quite disrupted and reported having a lot of daytime tiredness. The Veteran reported having a low appetite and stated that he had lost weight. He also indicated that he could be very forgetful. The Veteran stated that he had a lot of hypervigilance, including constantly checking on things. He reported that he found himself feeling insecure if he were in a crowd or in unfamiliar circumstances. He also indicated that he had some symptoms of irritability and stated that he had very few friends as a result of these problems. He noted that loud noises caused him to be startled or to have flashbacks. The Veteran reported that nightmares did not occur on a nightly basis. He stated that he was not suicidal and that he had not been particularly violent or dangerous to others. The Veteran reported having two glasses of wine and a shot of vodka every night. He noted that he would drink beer instead of wine in the summer. The Veteran stated that he remained married, he had four children from his first marriage and seven grandchildren. He also had a daughter from his second marriage. Mental status examination performed in January 2009 revealed that the Veteran made good eye contact. The Veteran spoke clearly and had no dysarthria or aphasia. His mood was described as "appropriately concerned." He was not sad or tearful. The Veteran's affect seemed appropriate but he did express a desire to improve his situation. Thought content revealed no evidence of psychosis. He was not paranoid. As to cognitive testing, the Veteran had difficulty with tests of sentence recall. His pattern was consistent with depression. The Veteran had no decline in performance, as was common with anxiety. He was slow but accurate on the tapping test and the backwards months test. The examiner rendered Axis I diagnoses of PTSD and depression. A GAF score of 50 was assigned. At the time of a September 2009 psychiatric outpatient visit, the Veteran indicated that his wife told him that he was very irritable. The Veteran stated that he had been hypervigilant. He reported that he had nightmares three times per month but his hypervigilance was almost continuous. Mental status examination performed in September 2009 revealed he was pleasant and able to focus well when talking to the examiner. His speech had a normal rate and rhythm, with no evidence of dysarthria or aphasia. Thinking was logical and the Veteran was not psychotic in any way. His mood was euthymic and his affect was appropriate. He seemed to have reasonable judgment and was definitely competent. The Veteran indicated that he had no suicidal thoughts and despite being irritable, he was not aggressive or violent. A diagnosis of chronic PTSD with chronic irritability was rendered. The examiner assigned a GAF score of 52. In a December 2009 letter, the Veteran's treating physician at the Worcester VA Outpatient Clinic indicated that since January of this year he had been treating the Veteran for depression, in the context of PTSD. It was noted that there had been difficulty finding a medicine that could help with the Veteran's problems of irritability and hypervigilance. The physician stated that these symptoms were almost assuredly secondary to PTSD. The physician indicated that the medication paroxetine had had some benefit but had not helped in the area of sleeping. The Veteran was noted to have frequent nightmares. Several medications had been tried without benefit. The physician stated that until the Veteran was able to sleep well, and thereby have good energy the next day, he did not think that the Veteran would be able to hold a job. He noted that the Veteran had applied for unemployability. The physician stated that as of this moment the Veteran was definitely unemployable. He noted that given the difficulty they had had in finding any kind of treatment that would seem to work, he was not sure that the Veteran would become employable in the near future. In a December 2009 letter, a VA R.N. from the VetCenter indicated that the Veteran continued to participate in the PTSD group. She noted that the Veteran reported that he continued to be bothered by nightmares and was up two to three times per night for approximately 20-30 minutes. The Veteran stated that he was having increasing problems at home managing his anger. He reported that his family walked on egg shells in order not to anger him. The Veteran stated that he had a problem trusting others, especially those in authority. He had worked as a police officer for 34 years. He retired in 2004 due to increasing stress at work and increasing anxiety. When he worked, the Veteran indicated that he preferred to work alone and tried to avoid his supervisors and co-workers. The Veteran had been out of work numerous times in the past due to increased stress at work and his inability to stay focused and concentrate. The Veteran noted having memory problems. He stated that his depression had increased in severity affecting his ability to function independently. He had few friends and preferred to isolate. His affect was flat. The Veteran reported little patience with his family, who tended to keep a distance from him when he started to escalate. The Veteran was afforded an additional VA examination in December 2009. At the time of the examination, the Veteran was noted to be casually dressed and to have adequate hygiene. The examiner noted that the Veteran was dressed in shorts, which was notable for the very cold temperatures at the time of the examination. He was unshaven. Rate, volume, and articulation of speech were within normal limits. Affect was flat. His mood was depressed. The Veteran maintained good eye contact. Good rapport was established and the Veteran was generally open and cooperative with the questions asked. The Veteran reported in December 2009 that he had been retired for five years and felt that his concentration and depressive symptoms had worsened since that time. He indicated that his symptoms began to appear during the end of his career and he called in sick frequently in his last year on the job because he did not want to shave and would call in sick and not go to work. He also noted that the stress level was becoming high. He stated that he had tried to work other types of jobs but noted that the poor concentration and irritability interfered with his functioning and he made mistakes while at work. In December 2009, the Veteran described a typical day as being up quite early, sometimes before sunrise, due to poor sleep. He would remain at home and go for a walk in the afternoon. The Veteran reported that he checked the locks around his house every evening when he went to bed and every morning when he got up to make sure that it was not different. He acknowledged that he had become very focused on order and cleanliness in his home. He tried to keep himself busy by cleaning up around the house. His wife encouraged him to shower and shave regularly. He used to take care of the bills but now his wife did as he had difficulty keeping up and made mistakes. The Veteran used to play golf but he did not now and had no other hobbies that he engaged in. He reported feeling closest to his wife but had a lot fewer friends than he used to. He did not initiate social interactions with others and preferred to be alone. He used to go to Fenway Park but did not go anymore because of the crowds. He reported seeing his children and grandchildren on holidays and birthdays but did not like to leave the home and did not enjoy playing with his grandchildren as much as he had in the past. The Veteran noted having nightmares twice a week where he woke up sweating and distressed. He typically would get out of bed for awhile before trying to go back to sleep. He had anxiety and tension when exposed to triggers that reminded him of his Vietnam experiences. The triggers included seeing fires, loud noises, or Vietnamese people. When asked about intrusive thoughts, the Veteran reported thinking about things that he should have done related to experiences in Vietnam; however, this appeared to be more of a ruminative quality than intrusions. The Veteran made an effort to avoid thoughts, feelings, and conversations related to his military experiences. He endorsed emotional numbing. He also reported detachment from others. The Veteran stated that it was hard for him to get close to anyone. He reported that this appeared to be getting worse. He also endorsed anhedonia and did not find it enjoyable to play golf or play with his grandchildren. The Veteran had hyperarousal symptoms, such as sleep disturbance every night. He had irritability much of the time and found that little things made him angry. He tried to walk away when that happened and would break things if no one were around. The Veteran had difficulties with concentration, finding himself very forgetful, and having difficulty retaining anything he would read. Hypervigilance in the form of lock checking and sitting with his back to the wall was also present. Exaggerated startle response was also found. The Veteran had depressed mood most of the day, nearly every day. He also had restlessness, fatigue, low energy, feelings of hopelessness and worthlessness, and recurrent thoughts of death. He indicated that he felt that his family might be better off without him but denied any plan or intent to act on these thoughts. He would not harm himself because of the children. The Veteran had given his weapon to his son as he felt he might be a danger if he had a gun. The Veteran's wife indicated that he was obsessed with garbage and could not throw away anything unless it was double wrapped. He cleaned countertops too many times, lined up clothes to wear on chairs again, walked around the house with a wet index finger, and picked lint up off of the floors. The Veteran noted that he was very concerned about the house being clean and orderly. He did not feel that he spent a lot of time engaging in these activities or that it was excessive. It was not distressing to him and he did not meet the criteria for obsessive-compulsive disorder. The Veteran denied experiencing any visual or auditory hallucinations. There was no evidence of delusions. Mental status examination in December 2009 revealed that the Veteran was oriented to person, place, and time. He was able to spell words backwards and perform serial sevens. He had difficulty naming the presidents in reverse order. Short term memory was slightly impaired. The examiner in December 2009 rendered Axis I diagnoses of PTSD; major depressive disorder, single episode, moderate; and alcohol abuse. A GAF score of 50 was assigned. The examiner indicated that the Veteran's PTSD appeared to have worsened in recent years. It was noted that the GAF score of 50 reflected a severe degree of impairment in social, occupational, and interpersonal functioning. The Veteran was experiencing significant anxiety and depressive symptoms. His anxiety disorder was deemed related to his military service and his depression was more likely secondary to his PTSD. Taken together, these symptoms exerted a negative impact on his functioning and would likely interfere with his ability to obtain and maintain gainful physical or sedentary employment. PTSD Evaluation prior to January 20, 2009 After a review of all the evidence, lay and medical, the Board finds that the criteria for a disability evaluation in excess of 50 percent were not met or nearly approximated prior to January 20, 2009. For the period prior to January 20, 2009, the Board finds that the Veteran's PTSD symptoms were not shown to be more than moderate in degree and only moderately impacted social and occupational functioning. The Veteran's PTSD symptoms and the severity of his symptoms did not more nearly approximate the criteria for a 70 percent disability (occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood) prior to this time. 38 C.F.R. §§ 4.3, 4.7. As mentioned above, for a rating in excess of 50 percent, the PTSD would have to manifest deficiencies in most occupational and social areas, such as work, school family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideations; 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 worklike settings); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. Prior to January 20, 2009, the Veteran was not shown to have suicidal plans or intentions. There were no findings or assertions of suicidal or homicidal plans or intentions at the time of the March 2007 or April 2008 VA examinations. While the Veteran was noted to check the locks and windows at night prior to going to bed, there were no obsessional rituals found which interfered with routine activities. Speech was not found to be intermittently illogical, obscure, or irrelevant at any time during this period, including at the March 2007 and April 2008 VA examinations. Although the Veteran was noted to have panic episodes, these were limited to when he was in stressful situations or when around crowds. While depression was noted at the time of an April 2008 VA examination, it was not found to be near-continuous. While the Veteran indicated that he was easily irritated and impatient, there were no periods of violence. He was also found to be alert and oriented to time, place, and person during this time frame. There were also no findings of neglect of personal appearance and hygiene prior to January 20, 2009. As to relationships, while the Veteran reported that he tended to isolate and preferred to be alone, he was still married and stated he saw his daughter from his second marriage on a weekly basis. The Veteran also reported that he got along with his children and seven grandchildren. Furthermore, the GAF scores of 55 assigned at the time of the March 2007 and April 2008 VA examinations are indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that without those examples, differentiating between rating evaluations would be extremely ambiguous. Id. at 442. With this in mind, the evidence shows that the Veteran's overall PTSD picture prior to January 20, 2009, was adequately contemplated by the existing 50 percent rating. The Veteran did suffer from sleep problems, but this is specifically listed under the criteria for a 30 percent rating, a lower rating than the current 50 percent evaluation. Flattened affect, disturbance of motivation and mood, and difficulty in establishing and maintaining relationships are specifically contemplated in the 50 percent rating criteria. The same is true with the Veteran's depression and anxiety, which are both symptoms contemplated under the 30 percent PTSD disability rating. A 50 percent PTSD disability rating also considers "disturbances of motivation and mood" which would include the Veteran's reported depression and anxiety symptoms. Despite the Veteran's contention that his PTSD symptoms warranted an evaluation in excess of 50 percent, the Board finds that the evidence of record does not support this contention prior to January 20, 2009. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for an increased rating in excess of 50 percent for PTSD prior to January 20, 2009, and the appeal for a higher rating for this period is not warranted. As the preponderance of the evidence is against a higher rating for this period, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. PTSD Evaluation from January 20, 2009 The Board finds that, with the resolution of reasonable doubt in the Veteran's favor, the criteria for a 70 percent disability evaluation for PTSD have been more nearly approximated for the period from January 20, 2009. The Board finds that for this period the Veteran's PTSD has caused occupational and social impairment with deficiencies in most areas including difficulties in the work environment, mood problems, impaired impulse control, unprovoked irritability, difficulty in adapting to stressful circumstances, an inability to establish and maintain effective relationships, near continuous depression, lack of energy/motivation, intrusive thoughts, and obsessional rituals. For the period from January 20, 2009, the Veteran has experienced difficulty obtaining and maintaining employment as a result of his PTSD, and difficulty maintaining relationships with all others but close family members. It has further been reported in VA examination reports, VetCenter records, and VA outpatient treatment records that the Veteran has impaired impulse control and unprovoked irritability, as well as daily episodes of depression for this period. The Veteran has also been found to have clinically significant distress or impairment in social, occupational, and other important areas of functioning, to include withdrawing from others and only interacting with his family, including at the time of his most recent VA examination. The Veteran has reported and has been found to prefer social isolation. Moreover, the Veteran has been noted to have obsessional rituals such as checking the locks. In addition, the assigned GAF score of 50 at the time of the January 20, 2009 outpatient visit and at the time of his most recent VA examination is indicative of serious symptoms and/or serious impairment in social, occupational or school functioning, consistent with the 70 percent rating criteria of occupational and social impairment, with deficiencies in most areas including work and difficulty in adapting to stressful circumstances including work or a work like setting. For the above reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that, for the time period from January 20, 2009, the Veteran's PTSD symptoms more nearly approximated the requirements for a schedular rating of 70 percent under Diagnostic Code 9411. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Board concludes that the Veteran's disability picture does not more nearly approximate the criteria for a 100 percent rating criteria under DC 9411 for this period. 38 C.F.R. § 4.130. The lay and medical evidence does not show that the Veteran has total occupational and social impairment, including 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; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. While the Veteran has been assigned a total rating based on individual unemployability under 38 C.F.R. § 4.16, the total rating was based on all his service-connected disabilities (including gunshot wound, right knee disability, tinnitus, hearing loss, and PTSD), rather than just the PTSD. When rating only the PTSD, the Board finds that the symptomatology and social and industrial impairment due to symptoms associated with the Veteran's PTSD more nearly approximates the 70 percent disability rating criteria, which specifically recognizes and rates based on occupational and social impairment, with deficiencies in most areas including work and difficulty in adapting to stressful circumstances, including work or a work like setting. See Mauerhan at 441-443 (if the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned). Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation 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." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 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. Id. In this case, the schedular rating criteria contemplate the impairments and symptoms associated with the Veteran's PTSD. The symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested difficulty sleeping, depression, anxiety, being startled easily, unprovoked irritability, obsessional rituals, and difficulty with maintaining work and social relationships. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. The Board notes that the Veteran has been granted a TDIU based upon his overall service-connected disabilities, which includes his PTSD. There have been no findings by any VA examiner that his PTSD alone causes total occupational impairment. Because the schedular rating criteria is adequate to rate the Veteran's disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R.§ 3.321(b)(1). ORDER A disability evaluation in excess of 50 percent for PTSD prior to January 20, 2009 is denied; a 70 percent disability evaluation for PTSD from January 20, 2009 is granted. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs