Citation Nr: 1319786 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 08-28 852 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial evaluation greater than 30 percent for posttraumatic stress disorder (PTSD), prior to March 15, 2012. 2. Entitlement to an increased evaluation greater than 70 percent for PTSD subsequent to March 15, 2012. 3. Entitlement to an initial evaluation greater than 10 percent for gastroesophageal reflux disease. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from May 1992 to June 2002 and from November 2003 to December 2007. He had a period of active duty for training from August 1990 to January 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office in Seattle, Washington (RO). Jurisdiction rests with the RO in Lincoln, Nebraska. The Veteran testified at an August 2011 hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is associated with the claims file. The Veteran's appeal was remanded by the Board in February 2012 for VA examinations and updated VA treatment records from the Omaha, Nebraska VA Health Care System. The Veteran was provided VA a examination in March 2012, and the Veteran's updated VA treatment records from Omaha, Nebraska have been associated with his claims file. Accordingly, the Board finds that there has been substantial compliance with the directives of the February 2012 remand in this case, such that an additional remand to comply with such directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). The brief submitted by the Veteran's representative in May 2013 as well as the July 2012 Supplemental Statement of the Case both list the issue of entitlement to an increased evaluation for residuals of a traumatic brain injury as an issue on appeal. However, in its February 2012 decision, the Board dismissed the issue of entitlement to an increased evaluation for traumatic brain injury based upon the Veteran's request to withdraw that issue during his August 2011 hearing before the Board. Accordingly, as that issue was dismissed by the Board in February 2012, it is not currently on appeal, and the Board does not have jurisdiction to address it at this time. The issue of entitlement to an initial evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD) is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to March 15, 2012, the Veteran's posttraumatic stress disorder (PTSD) was manifested by nightmares, hypervigilance, poor sleep, exaggerated startle response, depression, avoidance of trauma-related stimuli, avoidance of crowds, social isolation, numbing of emotions, anxiety, problems with concentration, loss of interest in things previously enjoyed, irritability and outbursts of anger, short temper, mood swings, difficulty in school, concentration problems, memory problems, impaired impulse control, good or fair hygiene, good eye contact, predominantly normal speech, good insight and judgment, depressed mood, restricted affect, linear thought process, normal thought content, and no suicidal or homicidal ideation. 2. On and after March 15, 2012, the Veteran's PTSD was manifested by short temper, memory impairment, irritability, outbursts of anger, sleep disturbance, social isolation, exaggerated startle response, anxiety, disturbances in motivation and mood, difficulty engaging in effective work and social relationships, difficulty adapting to stressful circumstances, intrusive thoughts and memories, nightmares, physical reactions to stressful circumstances, avoidance of trauma-related stimuli, loss of interest in activities previously enjoyed, difficulty concentrating, hypervigilance, difficulty in school, good grooming and hygiene, good eye contact, cheerful mood, appropriate or restricted affect, normal speech, logical and goal-directed thought process, relevant thought content, adequate insight, and no suicidal or homicidal ideation. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 50 percent, but no greater, for PTSD prior to March 15, 2012 have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a rating greater than 70 percent for PTSD on and after March 15, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has met all statutory and regulatory notice and duty to assist provisions. See 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 (2012). A November 2007 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records, VA medical treatment records, and identified private medical records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The record does not reflect that the Veteran is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1321 (Fed. Cir. 2010). The Veteran was most recently provided with a VA examination to assess the severity of his PTSD in March 2012. In a May 2013 brief, the Veteran's representative argued that the March 2012 VA psychiatric examination was inadequate because the examiner confirmed a diagnosis of PTSD and depression, but indicated that there were no depression symptoms in the examination report. The representative requested that the Veteran's claim for PTSD be remanded to clarify his PTSD symptoms. Although the Veteran's representative believes that the March 2012 VA psychiatric examination is inadequate, the Board does not agree. The March 2012 VA examiner diagnosed both depression and PTSD, and clearly identified the symptoms associated with each diagnosis, and explained that the depression symptoms were separate from the PTSD symptoms. The Board finds that the March 2012 VA psychiatric examination is adequate in this case, as it describes the symptoms associated with the Veteran's PTSD with sufficient detail to assess the current severity of that disability under the pertinent rating criteria. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ or Decision Review Officer (DRO) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The Veteran was afforded a hearing before a DRO in January 2009, and before the Board in August 2011. During each hearing, the hearing officer noted Veteran needed to provide evidence of the current nature and severity of his PTSD in order to substantiate his claim. The Veteran was assisted at both hearings by an accredited representative from the Veterans of Foreign Wars of the United States. The Veteran's representative, VLJ, and DRO all asked questions to ascertain the current symptomatology of the Veteran's service-connected PTSD. No pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or the representative. The hearings focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for an increased rating. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearings. Therefore, the Board finds that, consistent with Bryant, the VLJ and DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is rated as 30 percent disabling prior to March 1, 2012, and 70 percent disabling beginning March 15, 2012, under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Under the rating criteria, a 30 percent rating is warranted where the disorder is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation, due to such symptoms as: depressed mood, anxiety, suspiciousness, weekly or less often panic attacks, chronic sleep impairment, and mild memory loss, such as forgetting names, directions, recent events. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012) A 50 percent rating is warranted where the disorder is manifested by 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 for example, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is for application when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficult in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A maximum 100 percent evaluation is warranted when there is total occupational and social impairment due to such symptoms as: gross impairment in thought process or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. Global Assessment of Functioning (GAF) scores are a scale reflecting the 'psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.' See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), p. 32). GAF scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 and 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 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and a veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2012). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). Ratings are assigned according to the manifestation of particular symptoms, but the use of a term "such as" in 38 C.F.R. § 4.130 demonstrates 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. Mauerhan, 16 Vet. App. 436. Service treatment records from the last year of the Veteran's active duty service show diagnoses of and treatment for PTSD. A November 2006 treatment record notes the Veteran's reported symptoms of nightmares, hypervigilance, poor sleep, exaggerated startle reflex, avoidance of trauma-related stimuli, avoidance of crowds, depression, and social isolation. He denied suicidal thoughts. Mental status examination revealed the Veteran to be casually dressed and well-groomed. He was intelligent, cooperative, and polite. Eye contact was appropriate. Rate of speech was average without looseness, blocking, tangentiality, or pressure of speech. Speech latency was average. The Veteran denied auditory or visual hallucinations and did not appear to be responding to internal stimuli. He was not distractible by sights or sounds outside of the room. Insight and judgment were intact. The diagnosis was PTSD with daytime hypervigilance and nighttime nightmares. A GAF score of 55 was assigned. A December 2006 record reveals that the medication that he was prescribed to help with his nightmares was not helping. He noted that he expected to be separated from service after his upcoming medical board due to physical limitations. He continued to take business and Russian study courses, and indicated that school was going well and he as generally feeling good. Examination showed the Veteran to be casually dressed and well-groomed. Insight and judgment were intact. The diagnosis was PTSD with no discernible improvement in nightmares. In January 2007, the Veteran reiterated that his medication was not helping to decrease the intensity or frequency of his nightmares. He indicated that he continued to have trouble in crowds and was wary of loud noises. The Veteran was well-groomed and insight and judgment were intact. The diagnosis was PTSD. An April 2007 record shows that the Veteran continued to report nightmares, decreased with medication, and daytime startling. Examination showed the Veteran to have excellent grooming with casual dress. He was soft spoken, polite, and articulate. Insight and judgment were intact. The diagnosis was PTSD. An April 2007 Medical Evaluation Board consultation report indicates that the Veteran was able to work a job effectively and maintain a good grade point average while taking 12 credits of college courses. The record notes that his nightmares were significantly decreased and he was no longer bothered by stimuli from the environment as much. Mental status examination showed the Veteran to be clean and well-groomed with good personal hygiene. He was alert and fully oriented. Behavior was calm, cooperative, and interactive. Speech was normal and eye contact was appropriate. Mood was average and affect was congruent and euthymic with broad range and reactivity. Thought process was generally linear, logical, and goal-directed. Thought content was free of suicidal or homicidal ideation and any evidence of psychosis. Judgment was good and insight was broad. Impulse control was good. The diagnosis was PTSD manifested by symptoms including persistent reexperiencing of traumatic events in the form of nightmares and intrusive thoughts, persistent avoidance of stimuli associated with those traumas, persistent numbing of general responsiveness, and persistent symptoms of increased arousal. A GAF score of 81-90 was assigned. A June 2007 treatment record reveals that the Veteran continued to complain of nightmares, daytime startle, and re-experiencing symptoms, which were improving. Examination showed the Veteran to be polite, soft spoken, and articulate, with casual dress. Insight and judgment were intact. The diagnosis was PTSD. In July 2007, the Veteran complained of nightmares, re-experiencing anxiety, and startle during the day. He also complained of problems with concentration, noting that although he understands the material presented in class and studies hard, two days later he has a great deal of difficulty retrieving the information for a quiz. Examination showed the Veteran to have excellent grooming with intact insight and judgment. The diagnosis was PTSD. In a July 2007 statement, the Veteran reported that he had PTSD symptoms including poor sleep, nightmares, difficulty concentrating, and hypervigilance. He noted that he had difficulty being in a classroom at school and focusing on the task, as well as difficulty remembering some of the most routine things. He indicated that he was also bothered by stimuli from the environment. A September 2007 treatment record shows that the Veteran continued to report nightmares and trouble sleeping. In October 2007, the Veteran reported nightmares. Examination showed that he was well-groomed. Insight and judgment were intact. The diagnosis was PTSD. In January 2008, the Veteran underwent a VA psychiatric examination. He complained of symptoms including insomnia, nightmares, hypervigilance, exaggerated startle response, irritability, and forgetfulness. He noted that the symptoms occurred constantly and affected his daily functioning, as he had difficulty focusing in school and was detached from his classmates. He described distant relationships with his parents and siblings but noted that he had a good relationship with his significant other. He explained that he felt detached and isolated in his daily activities and described social isolation. The examiner noted that the Veteran also had symptoms of fear and avoidance of trauma-related stimuli, persistent markedly diminished interest or participation in significant events, persistent feeling of detachment or estrangement from others, persistent irritability or outbursts of anger, and persistent difficulty concentrating. Mental status examination showed the Veteran to be alert and fully oriented. Appearance and hygiene were appropriate. Affect and mood were normal and communication was within normal limits. Speech was normal and concentration was also normal. Panic attacks were absent, but there were signs of suspiciousness such as being suspicious of people. There was no delusional history and ho hallucination history. There were no obsessional rituals. Thought process was appropriate and judgment was not impaired. Abstract thinking was normal and memory was within normal limits. Suicidal and homicidal ideation were absent. The diagnosis was PTSD, and a GAF score of 70 was assigned. A July 2008 VA treatment record notes the Veteran's complaints of trouble with memory and concentration. The Veteran stated that he was married with two children. Mental status examination showed the Veteran to be alert and fully oriented with normal speech rate but slow rhythm. Language was intact. Mood was depressed and affect was blunted, restricted, or constricted. There was no evidence of hallucinations or illusions and there was no unusual thought content. The Veteran denied suicidal or violent ideation. Insight and judgment were good and memory was intact. The physician diagnosed PTSD and indicated that the Veteran had angry, irritable moods and dysphoria exacerbated by history of losses and psychosocial stressors. The diagnosis was PTSD, and a GAF score of 55 was assigned. In August 2008, the Veteran complained of poor sleep. He indicated that his mood was slightly improved with the addition of a new medication, and noted that he was less anxious. Examination showed the Veteran to have good grooming and hygiene and normal motor behavior. Eye contact was good. The Veteran's facial expression was sad, but his attitude was cooperative. Mood was depressed and affect was constricted. Speech was relevant and spontaneous. Thought processes were logical and goal-directed and thought content was relevant. Insight was adequate and there was no suicidal or homicidal ideation. The diagnoses were PTSD and depression, and a GAF score of 65 was assigned. Another August 2008 record notes the Veteran's continued sleep problems, which were improving, and that the Veteran was starting school in a few days. Examination showed that grooming and hygiene were good and motor behavior was normal. Eye contact was good and facial expression was normal. Attitude was cooperative, mood was neutral, and affect was euthymic. Speech was fluent, thought processes were clear, thought content was appropriate, and insight was clear. There was no suicidal or homicidal ideation. The diagnosis was PTSD. Private treatment records from August 2008 indicate that the Veteran had PTSD with symptoms including poor sleep and frequent nightmares. In September 2008, the Veteran underwent another VA psychiatric examination. However, the examiner only addressed the Veteran's symptoms with respect to his service-connected traumatic brain injury. The Veteran's PTSD symptoms were not discussed or considered. Because the examiner only considered the Veteran's psychiatric symptoms related to his traumatic brain injury, the Board does not find the September 2008 examination to be relevant to determining the severity of the Veteran's PTSD. An October 2008 VA treatment record notes the Veteran's complaints of difficulty with school, including poor memory, poor concentration, and lack of focus. He noted that his mood was more stable and he felt better overall. He stated that his kids and his marriage were going well, and denied suicidal and homicidal thoughts. Examination showed the Veteran to have good grooming and hygiene, normal motor behavior, and good eye contact. The Veteran's facial expression was normal and responsive, and his attitude was cooperative. His mood was cheerful and his affect was appropriate. Speech was relevant and spontaneous, thought processes were logical and goal-directed, thought content was relevant, and insight was adequate. The diagnosis was PTSD. In January 2009, the Veteran's wife submitted a statement with regard to the Veteran's symptoms. She stated that the Veteran's PTSD symptoms included memory loss, poor concentration, irritability, short temper, frustration, nightmares, sleep disturbance, exaggerated startle response, mood swings, and depression. She noted that he had memory loss for whether he had told his wife something, such as events that he had planned and their timing. She also reported that the Veteran struggled in school due to poor information recall. During a January 2009 hearing before the RO, the Veteran testified that he had PTSD symptoms including impairment of short- and long-term memory; retention of only highly learned material; forgetting to complete tasks, such as scheduling family activities and forgetting to notify the family; trouble concentrating; difficulty with school and having to repeat classes; impaired impulse control, including overspending; disturbances in motivation or mood; irritability; difficulty establishing and maintaining work and social relationships, as he did not get along with other students; feeling uncomfortable in group situations; social isolation; lack of activities and hobbies; nightmares; and flashbacks. In March 2009, the Veteran underwent another VA psychiatric examination, which addressed both the Veteran's PTSD and his service-connected traumatic brain injury. The Veteran reported that he was frustrated by the concentration problems caused by his traumatic brain injury. He reported symptoms including nightmares, sleep issues, isolation, as well as social and occupational dysfunction. He stated that his triggers for reactivation symptoms included smells and noises, and indicated that he only slept for three hours per night. He noted that he has become physically aggressive at times in bed due to his nightmares. The Veteran also complained of anhedonia, feeling cut off from others, and feeling self-conscious. He noted that he had a short temper and irritability, as well as frustration over problems concentrating. He also described hypervigilance and feeling helpless. The Veteran stated that his wife was a strong social support for him, and indicated that he was proud of his children and engaged in their activities. In that regard, he noted that he was a leader in his son's Boy Scout troop. He reported that he was enrolled in school and trying to obtain a degree in accounting, but that he was struggling in his course work. Mental status examination showed the Veteran to be well dressed and well-groomed. His eye contact was engaging and his demeanor was pleasant and cooperative. His speech was somewhat slow and methodical and lacked a quick spontaneity, but was linear and goal-directed. Thought processing was cogent and logical and there was no loosening of associations or flight of ideas. Mood was somewhat dysphoric with a mildly restricted affect. The Veteran denied suicidal and homicidal ideation and there were no perceptual distortions, such as hallucinations or delusions. The Veteran also denied any abstract thinking. Cognitively, he was alert and fully oriented with sustained attention throughout the interview. Digit span testing and gross memory testing was intact. Insight and judgment were good. The examiner opined that, based upon both PTSD and the Veteran's cognitive deficits related to his traumatic brain injury, the Veteran would be unable to maintain both full-time work and full-time educational requirements. The examiner explained that, although he was highly motivated to succeed, there were certain decompositions of neurobehavioral symptoms which impaired his overall functioning. The diagnoses were PTSD, severe and chronic; and cognitive disorder secondary to traumatic brain injury. A GAF score of 52 was assigned. An April 2009 VA treatment record states that the Veteran reported trouble concentrating and learning. He noted that his PTSD symptoms were okay, but that sleep was not great. Examination showed the Veteran to have fair grooming and hygiene. Motor behavior was normal and eye contact was good. Facial expression was normal and responsive and attitude was cooperative. Mood was neutral and affect was appropriate and variable. Speech was relevant and spontaneous, thought processes were logical and goal-directed, thought content was relevant, and insight was adequate. There was no suicidal or homicidal ideation. The diagnoses were PTSD and traumatic brain injury. A June 2009 VA treatment record reveals that the Veteran denied suicidal and homicidal ideation, and psychosis. He reported that school was going well and his family was well. Examination showed the Veteran to have good grooming and hygiene, normal motor behavior, and good eye contact. The Veteran's facial expression was normal and responsive and his attitude was cooperative. Mood was depressed and affect was appropriate and variable. Speech was relevant and spontaneous and thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. There was no suicidal or homicidal ideation. The diagnoses were PTSD and attention deficit hyperactivity disorder. VA treatment records from October 2009 to January 2012 reflect continued complaints of and treatment for PTSD. In October 2009, the Veteran complained of difficulty focusing and concentrating at school as well as performance problems at school. Mental status examination showed the Veteran to have good grooming and hygiene, normal motor behavior, and good eye contact. Facial expression was normal and responsive and attitude was cooperative. Mood was neutral and affect was appropriate. Speech was relevant and spontaneous and thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnoses were PTSD and traumatic brain injury. A December 2009 mental status examination showed the Veteran to be pleasant with fair hygiene. Mood was described as neutral and affect was restricted. Speech was normal and thought processes were goal-directed and logical. Thought content and behavior were normal with no evidence of psychosis. The Veteran denied suicidal and homicidal ideation. Judgment and insight were fair, but psychomotor activity was abnormal. Intelligence was above average. The diagnosis was chronic PTSD. A June 2010 record reveals the Veteran's complaints of difficulty with school, memory problems, trouble sleeping, irritability. On examination, the Veteran was appropriately dressed with good eye contact. The diagnoses were PTSD and post-concussion syndrome. A GAF score of 60 was assigned. An October 2010 record notes that the Veteran was having difficulty with short-term memory in school, irritability, difficulty sleeping, and nightmares. He also noted feeling uncomfortable in a large classroom, and feeling more aware and vigilant with some of the students in class. The diagnoses were PTSD and post-concussion syndrome, and a GAF score of 58 was assigned. In December 2010, the Veteran complained of intrusive military memories, difficulty sleeping, nightmares, being super alert, sensory overload when in public places, loss of interest in things he once enjoyed, and social isolation. He identified how his symptoms negatively impacted his life. Mental status examination showed the Veteran to have good grooming and hygiene and normal motor behavior. Eye contact was good and facial expression was normal and responsive. Attitude was cooperative. Mood was neutral and affect was appropriate and variable. Speech was relevant and spontaneous and thought processes were goal-directed and logical. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD. February 2011 records reflect that the Veteran was skipping classes in school because he was not able to be in the classroom and feeling overwhelmed. He noted memory difficulty and hypervigilance. He reported having some numbed feelings and nightmares with sleep disturbance. He also noted irritability and hyperarousal. The diagnosis was PTSD, and a GAF score of 55 was assigned. A March 2011 record reflects a diagnosis of PTSD and a GAF score of 58. Another March 2011 record indicates that the Veteran complained of difficulty sleeping and struggling in school. He noted difficulty concentrating and with memory as well as hypervigilance and intrusive thoughts. Mental status examination showed good grooming and hygiene and normal motor behavior. Eye contact was good. Mood was neutral and affect was blunted. Thought processes were normal and thought content was relevant. Insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD. In April 2011, the Veteran indicated that there were no significant changes, and he continued to experience moderate to severe PTSD symptoms, which made it difficult to function effectively on a daily basis. Mental status examination showed the Veteran to have good grooming and hygiene, normal motor behavior, and good eye contact. Facial expression was normal and responsive and attitude was cooperative. Mood was neutral and affect was appropriate and variable. Speech was relevant and spontaneous and thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD, and a GAF score of 53 was assigned. A May 2011 record notes that the Veteran volunteered to help with Boy Scouts, and would be gone for the month of June. Mental status examination showed the Veteran to have good grooming and hygiene and normal motor behavior. Eye contact was good. Mood was neutral and affect was appropriate. Speech was relevant and spontaneous and thought process was logical and goal-directed. Thought content was relevant. Insight was adequate and the Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD and a GAF score of 55 was assigned. In June 2011, the Veteran began prolonged exposure therapy. Mental status examination showed him to have good grooming and hygiene. Motor behavior was normal and eye contact was good. Mood was neutral and affect was appropriate. Speech was normal and thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD and a GAF score of 55 was assigned. A July 2011 record notes the Veteran's fear of fireworks and that he avoided riding his bike so that he did not hear them. He noted that he went shopping three times that week, and experienced high anxiety. Mental status examination showed good grooming and hygiene. Motor behavior was normal and eye contact was good. Mood was neutral and affect was appropriate. Speech was relevant and spontaneous, thought processes were logical and goal-directed, and thought content was relevant. Insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD and a GAF score of 55 was assigned. Another July 2011 record notes that the Veteran had good grooming and hygiene and normal motor behavior. Eye contact was good, mood was neutral and affect was appropriate. Speech was retarded but thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD, and a GAF score of 57 was assigned. An August 2011 record reflects that the Veteran experienced low to moderate anxiety when shopping and at the mall. He also noted that he took his son and a friend to a water park and was starting to push himself more to do things he stopped doing and had more confidence that he could manage his anxiety. He noted that the re-experiencing symptoms continued to be frequent and moderate to severe in severity. Mental status examination showed good grooming and hygiene with normal motor behavior. Eye contact was good. Mood was neutral and affect was appropriate. Speech was relevant and spontaneous and thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD and a GAF score of 58 was assigned. In August 2011, the Veteran reported experiencing intrusive thoughts and memories quite a bit; repeated disturbing dreams quite a big; reliving stressful experiences from the past a little bit; feeling upset when reminded of a stressful experience moderately; having physical reactions when something reminds him of his experiences quite a bit; avoiding thinking about or having feelings about the stressful experiences moderately; extreme loss of interest in things that he used to enjoy; feeling distant or cut off from others quite a bit; feeling extremely emotionally numb and unable to have loving feelings; having extreme trouble sleeping; feeling irritable or having angry outbursts quite a bit; having difficulty concentrating quite a bit; being superalert quite a bit; and feeling easily startled quite a bit. Another August 2011 record reflects a diagnosis of PTSD and a GAF score of 56. In an August 2011 letter, a Licensed Clinical Social Worker, Lisa Barnes, stated that, since returning from deployments in Iraq and Afghanistan, the Veteran has had problems with depression, anxiety, irritability, hypervigilance, hyperstartle, nightmares, flashbacks, feelings of numbness, and loss of interest in things he once enjoyed. She noted that the Veteran's PTSD symptoms had a profound impact on his daily living and made it difficult for him to establish and maintain effective relationships. She also indicated that his symptoms caused reduced productivity at school as well as difficulties concentrating, long- and short-term memory impairment, and chronic sleep problems. During an August 2011 hearing before the Board, the Veteran testified that his PTSD caused symptoms such as depression, anxiety, hypervigilance, hyperstartle, nightmares, flashbacks, exaggerated startle reflex, difficulty concentrating, memory impairment, and sleep problems. He noted that he had difficulty at school, and that he has repeated several classes. He described his family life and relationships as generally good, but noted impaired impulse control evidenced by poor control over spending money. In that regard, he indicated that he took a loan out without his wife knowing just to buy things, and used spending as a coping mechanism. He also reported that he had irritability and poor temper, and that he once broke a trashcan. He denied any physical violence. He complained of difficulty adapting to stressful circumstances, such as dealing with teenage children, and difficulty establishing and maintaining effective relationships. He described social isolation, noting that he occasionally saw people from his son's boy scout troop, but that he did not have any friends that he hung out with. He also noted that he avoids crowds, had poor motivation, and had poor appearance and needed to be reminded to get dressed. The Veteran stated that his symptoms have not changed dramatically since service, and indicated that they have mostly been consistent. A September 2011 VA treatment record indicates that the Veteran reported he had continued distressing thoughts and memories of military experiences and continued to avoid situations that made him feel uncomfortable or anxious and continued to feel emotionally numb. Mental status examination revealed the Veteran to have good grooming and hygiene; normal motor behavior; good eye contact; neutral mood; appropriate affect; relevant and spontaneous speech; logical and goal-directed thought process; relevant thought content; and adequate insight. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD, and a GAF score of 55 was assigned. Another September 2011 record indicates that the Veteran was concerned about emotional numbness and lack of interest in things he once enjoyed. He indicated that he isolated in his basement the majority of the time and experienced emotional numbness. He noted that his re-experiencing symptoms were reduced. Mental status examination showed good grooming and hygiene, normal motor behavior, and good eye contact. Mood was neutral and affect was appropriate and variable. Speech was relevant and spontaneous and thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD. A third September 2011 record notes that the Veteran was more involved with the family and not isolating in his basement. Mental status examination was normal. The diagnosis was PTSD, and a GAF score of 58 was assigned. An October 2011 VA treatment record notes that the Veteran was avoiding less but still experiencing emotional numbness or disinterest. He noted that his PTSD symptoms were moderate, but he felt that he was managing them in a better way. Mental status examination was normal. The diagnosis was PTSD, and a GAF score of 60 was assigned. A November 2011 record states that the Veteran reported no significant changes. He noted that he was isolating and avoiding less. He stated that he was struggling with his online Master's degree program and was thinking about dropping out, noting that he preferred to work full-time but was having difficulty finding a job. Mental status examination showed the Veteran to have good grooming and hygiene and normal motor behavior. Eye contact was good. Mood was neutral and affect was appropriate. Speech was relevant and spontaneous and thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD. A January 2012 VA treatment record reflects that the Veteran reported poor sleep and nightmares. He denied suicidal ideation. The diagnosis was PTSD, and a GAF score of 55 was assigned. Another January 2012 VA treatment record notes that the Veteran felt that things were going well for him, overall. He reported that he was actively involved with his family and got out more. He indicated that he continued to think about his military experiences but was less emotionally reactive to the distressing memories. He expressed frustration over unemployment and that he felt that businesses did not want to hire veterans. He also noted that he failed his online MBA courses. Mental status examination showed the Veteran to have good grooming and hygiene. Motor behavior was normal and eye contact was good. Facial expression was normal and responsive. Attitude was cooperative. Mood was cheerful and affect was appropriate and variable. Speech was relevant and spontaneous and thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD, and a GAF score of 61 was assigned. In March 2012, the Veteran underwent another VA psychiatric examination. The Veteran complained of short temper, memory impairment, and irritability. He reported that he earned a Bachelor's Degree in Business Management and ended up with a grade point average of 3.05, although this was after having to repeat numerous classes. Thereafter, the Veteran enrolled in a Masters Degree program, but withdrew because it was too difficult and he fell behind, noting that he ended up with three F's. The examiner acknowledged that the Veteran had more than one psychiatric diagnosis, and that the symptoms attributable solely to his PTSD included irritability or outbursts of anger, difficulty falling or staying asleep, estrangement, affective restriction, exaggerated startle reaction, and difficulty with social interaction due to irritability or outbursts of anger. The Veteran also had anxiety, disturbances in motivation or mood, difficulty establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances. The examiner reported that the Veteran had symptoms of irritability and loss of interest in sex, loss of pleasure, self-dislike, agitation, loss of interest, indecisiveness, changes in sleeping pattern, concentration difficulty, pessimism, guilty feelings, self-criticalness, changes in appetite, and fatigue associated with his diagnosed depression. The examiner reiterated that it was possible to differentiate which symptoms were attributable to each diagnosis, and explained that the Veteran's cognitive disorder caused mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment; normal judgment; routinely appropriate social interaction; full orientation; normal motor activity; mildly impaired visual spatial orientation; and neurobehavioral effects which as irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. The examiner found that the effects of all of the Veteran's mental diagnoses caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The diagnoses included PTSD, cognitive disorder not otherwise specified, and depression not otherwise specified. A GAF score of 50 was assigned based solely on the Veteran's PTSD. After reviewing the evidence in the Veteran's claims file, the examiner stated that the Veteran's traumatic brain injury caused mild impairment with some areas of functioning falling within normal limits and one area of moderate impairment. The examiner noted that the Veteran still exhibited a diagnosis of PTSD and a new diagnosis of depression which was secondary to his PTSD. VA treatment records from March 2012 to August 2012 show continued complaints of and treatment for PTSD. In March 2012, the Veteran reported moderate disturbing intrusive memories and thoughts; frequent nightmares; moderate re-experiencing symptoms; moderate physical reactions to reminders of stressful experiences; moderate avoidance of thinking or talking about stressful experiences; moderate avoidance of activities or situations which remind him of stressful circumstances; some trouble remembering parts of the stressful experiences; significant loss of interest in activities; significant feelings of distance from others; substantial feelings of emotional numbness; moderate difficulty sleeping; significant irritability; significant difficulty concentrating; and some feelings of exaggerated startle response and feeling superalert. In March 2012, the Veteran complained of feeling easily startled and easily irritated. He noted a slight increase in re-experiencing and hyperarousal symptoms as well as other PTSD symptoms due to having contact with his military buddy. Mental status examination showed the Veteran to have good grooming and hygiene, good eye contact, cheerful mood, and appropriate affect. Speech was relevant and spontaneous, thought process was logical and goal-directed, and thought content was relevant. Insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD, and a GAF score of 58 was assigned. An April 2012 record notes the Veteran's complaints of irritability and difficulty finding a job. He also noted feeling worthless. He indicated that he decided to volunteer at summer camp, and was more involved with his family. He noted mild to moderate anxiety. Mental status examination showed the Veteran to have good grooming and hygiene, normal motor behavior, and good eye contact. Mood was cheerful and affect was appropriate. Speech was relevant and spontaneous and thought process was logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD. An August 2012 VA treatment record reflects that the Veteran reported that things were going well for him. He indicated that he spent the summer working for the Boy Scouts, and enjoyed it for the most part. He noted that he was job searching, but has been unsuccessful finding a job for the last year. Mental status examination showed the Veteran to have good grooming and hygiene, normal motor behavior, and good eye contact. Mood was cheerful and affect was appropriate. Speech was relevant and thought processes were logical and goal-directed. Thought content was relevant and insight was adequate. The Veteran denied suicidal and homicidal ideation. The diagnosis was PTSD. As noted above, the Veteran is currently assigned a 30 percent evaluation for his PTSD prior to March 15, 2012. A 30 percent evaluation contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242. The Veteran's GAF scores of 52, 53, 55, 56, 57, 58, and 60 indicate moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Veteran's GAF scores of 61 and 65 suggest some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well and has some meaningful interpersonal relationships. The GAF score of 81-90 denotes absent or minimal symptoms, good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, and no more than everyday problems or concerns. Id. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2012); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). Prior to March 15, 2012, the Veteran's PTSD symptoms included nightmares, hypervigilance, poor sleep, exaggerated startle response, depression, avoidance of trauma-related stimuli, avoidance of crowds, social isolation, numbing of emotions, anxiety, problems with concentration, loss of interest in things previously enjoyed, irritability and outbursts of anger, short temper, and mood swings. The Veteran also reported difficulty in school, including failing classes and skipping classes because he felt overwhelmed in the classroom. He also noted significant problems with concentration and both short- and long-term memory. He described impaired impulse control demonstrated by overspending and taking a loan out without his wife's knowledge to buy things and difficulty getting along with others outside his family, such as other students. The medical evidence shows that the Veteran always had good or fair hygiene and was well-groomed; was alert and fully oriented; had good or appropriate eye contact; and denied suicidal and homicidal ideation. Speech was usually normal, but on occasion speech had slow rhythm, was slow or methodical and lacked symmetry, or was retarded. Insight and judgment was always intact or good, and the Veteran regularly denied auditory and visual hallucinations. Mood was described as average, normal, depressed, or dysphoric, and affect was euthymic, normal, blunted, restricted, or constricted. Thought process was always linear, goal-directed, or appropriate, and thought content was normal. The medical evidence shows no evidence of panic attacks or obsessional rituals. After a thorough review of the evidence of record, the Board concludes that, although not all of the symptomatology described under the relevant diagnostic code is demonstrated, the Veteran's symptoms more closely approximate the requirements for a 50 percent evaluation for PTSD prior to March 15, 2012, as there is evidence of impairment of short- and long-term memory, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. However, an evaluation in excess of 50 percent is not for assignment in this case. While there is evidence of impaired impulse control, there is no evidence of suicidal ideation; obsessional rituals; illogical, obscure, or irrelevant speech; near-continuous depression or panic affecting the ability to function independently, appropriately, and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty adapting to stressful circumstances; or inability to establish and maintain effective relationships. Thus, although the evidence of record may demonstrate one of the symptoms contemplated in a 70 percent evaluation, the Veteran's disability picture prior to March 15, 2012 more closely corresponds to the requirements for a 50 percent evaluation. Thus, as the evidence does not more nearly approximate an evaluation greater than 50 percent, an increased evaluation in excess of 50 percent is not warranted for the Veterans PTSD prior to March 15, 2012. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran is currently assigned a 70 percent evaluation for his PTSD on and after March 15, 2012. A 70 percent disability rating contemplates 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 worklike setting); inability to establish and maintain effective relationships. Id. The Veteran's GAF score of 50 reflects serious symptoms or any serious impairment in social, occupational, or school functioning. The GAF score of 58 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 46-47. On and after March 15, 2012, the Veteran's PTSD symptoms included short temper, memory impairment, irritability, outbursts of anger, sleep disturbance, social isolation, exaggerated startle response, anxiety, disturbances in motivation and mood, difficulty engaging in effective work and social relationships, difficulty adapting to stressful circumstances, intrusive thoughts and memories, nightmares, physical reactions to stressful circumstances, avoidance of trauma-related stimuli, loss of interest in activities previously enjoyed, difficulty concentrating, and hypervigilance. The Veteran also reported that he earned his Bachelor's degree in Business Management, but had to repeat numerous classes in school. Also, he withdrew from a Master's program because he failed three classes and the program was too difficult. He noted that he worked a summer job with the Boy Scouts and was looking for a job. The medical evidence shows that the Veteran had good grooming and hygiene, good eye contact, cheerful mood, appropriate or restricted affect, normal speech, logical and goal-directed thought process, and relevant thought content. He had adequate insight and denied suicidal and homicidal ideation. After a thorough review of the evidence of record, the Board concludes that an evaluation greater than 70 percent is not warranted for the Veteran's PTSD on and after March 15, 2012. The evidence of record does not reflect 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 the activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Moreover, the Veteran reported that he worked at a summer job with the Boy Scouts and was looking for full-time employment. Thus, the evidence does not show total occupational and social impairment sufficient to establish a 100 percent disability rating for PTSD on and after March 15, 2012. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board has also considered the Veteran's symptoms which are not specifically contemplated by the Rating Schedule during both periods on appeal, such as nightmares, hypervigilance, sleep disturbance, poor concentration, exaggerated startle response, loss of interest, irritability, avoidance of crowds, mood swings, exaggerated startle response, and intrusive thoughts and memories. While those symptoms certainly contribute to the impairment caused by the Veteran's PTSD, they do not show occupational and social impairment sufficient to warrant a 70 percent evaluation prior to March 15, 2012, or a 100 percent evaluation on and after March 15, 2012. Mauerhan, 16 Vet. App. 436. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321(b)(1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The schedular ratings in this case are adequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected PTSD, but the medical evidence reflects that those symptoms are not present. The diagnostic criteria also adequately describe the severity and symptomatology of the Veteran's PTSD. He has not required hospitalization during the appeal period and marked interference of employment has not been shown. Therefore, the Veteran's disability picture is contemplated by the Rating Schedule; no extraschedular referral is required. Last, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for entitlement to a total disability rating based on individual unemployability is part of an increased rating claim when such claim is raised by the record. In this case, the Veteran does not contend, and the evidence does not suggest, that he is unemployable as a result of his service-connected PTSD. In fact, the Veteran recently reported that he worked a summer job with the Boy Scouts and that he was looking for full-time employment. Thus, the issue of entitlement to a total rating for compensation purposes based upon individual unemployability has not been raised by the evidence of record, and the issue is not before the Board at this time. ORDER Entitlement to an initial rating of 50 percent, but no more, is warranted for the Veteran's PTSD prior to March 15, 2012. Entitlement to a rating greater than 70 percent for PTSD, beginning March 15, 2012, is denied. REMAND During his August 2011 hearing before the Board, the Veteran testified that he received private treatment for his GERD. Although he believed that he had provided VA with copies of those private treatment records, review of the claims file reflects no private treatment records with regard to the Veteran's GERD. Accordingly, the RO should attempt to obtain any outstanding private treatment records relevant to the Veteran's GERD. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with a VA Form 21-4142 and request that he complete and submit it in favor of any private treatment records for his GERD. Additionally, in light of the changes to 38 U.S.C.A. § 5103A(2)(B), the RO must make two attempts for the relevant private treatment records or make a formal finding that a second request for such records would be futile. See Pub. L. No. 112-154, § 505, 126 Stat. 1165, 1193 (2012). All development efforts should be associated with the record. If, after making reasonable efforts to obtain these records, the RO is unable to secure same, notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) notify him that he is ultimately responsible for providing the evidence. Give the Veteran an opportunity to respond. 2. After completing the above development, and any other development deemed necessary, readjudicate the issue on appeal. If the benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board for appellate review, after the Veteran has had an adequate opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs