Citation Nr: 1320264 Decision Date: 06/24/13 Archive Date: 07/02/13 DOCKET NO. 10-03 451 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with bipolar mood disorder, not otherwise specified. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1966 to July 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in June 2008 and December 2009 by the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island. In the June 2008 rating decision, the RO granted service connection for PTSD with an evaluation of 30 percent effective December 19, 2007. In the December 2009 rating decision, the RO granted service connection for bipolar mood disorder, not otherwise specified, secondary to PTSD. Per the provisions of 38 C.F.R. § 4.14 (2012), the RO determined that a separate evaluation for bipolar mood disorder, not otherwise specified, could not be provided and therefore continued the evaluation of 30 percent. As a result, the issue is characterized as shown on the title page. FINDING OF FACT Throughout the pendency of the appeal, the Veteran's PTSD with bipolar mood disorder, not otherwise specified, was manifested by occupational and social impairment with reduced reliability and productivity, due to such symptoms as restricted affect, sleep impairment, nightmares, flashbacks, depression, anxiety, isolation, avoidance, exaggerated startle response, hypervigilance, hallucinations, delusions, and obsessive/compulsive behavior, but not occupational and social impairment with deficiencies in most areas, due to such symptoms as obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, and neglect of personal appearance and hygiene. CONCLUSION OF LAW Throughout the pendency of the appeal, the criteria for a disability rating of 50 percent for PTSD with bipolar mood disorder, not otherwise specified, have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions with respect to the issue on appeal. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The information contained in a January 2008 letter satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Moreover, the Veteran was notified of regulations pertinent to the establishment of an effective date and disability rating in the January 2008 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records and VA treatment records have been obtained and associated with the claims file. The Veteran was also provided VA examinations in April 2008, December 2009, and August 2011. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The examiners reviewed the pertinent evidence of record and the Veteran's lay statements. Additionally, the examinations provided sufficient information to decide the issue on appeal. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). As such, the Board finds the examinations to be sufficient and adequate for rating purposes. 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, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The Board has thoroughly reviewed all of the evidence in the Veteran's claims file. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter on appeal. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating 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 Rating Schedule but 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 for an increased rating for a 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 that 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. In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV), a global assessment of functioning (GAF) score reflects the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV, American Psychiatric Association (1994), pp. 46-47; 38 C.F.R. §§ 4.125(a), 4.130 (2012). A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 indicates 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 51-60 represents 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). A GAF score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. The Veteran's service-connected disability has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides: A 30 percent disability rating is warranted when the Veteran experiences occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when the Veteran experiences occupational and social impairment with reduced reliability and productivity, due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is warranted when the Veteran experiences 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 work-like setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. The Veteran's service-connected disability is currently rated as 30 percent disabling for the entire appeal period. Therefore, to warrant a higher disability rating, the evidence must show occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A November 2007 VA social work record shows the Veteran reported that he had no interest in doing things. The Veteran felt grumpy and would separate from other people two to three times per week. He reported that his concentration was deplorable and that he had a hard time comprehending and remembering things, especially short-term things. He felt anxious in small rooms, had a hard time around large groups of people, avoided crowds, startled with loud noises, was always looking around to see someone's shadow, and checked the perimeter of a building other than his home. The Veteran reported that his marriage was going pretty well and that he had contact with his next youngest brother approximately one time per month. The Veteran stated that because he did not want to get hurt again, he avoided making friends, although he did have some acquaintances. On examination, the Veteran was casually dressed and well-oriented, and his speech was coherent, relevant, and articulate. He denied suicidal and homicidal ideations but admitted to having thoughts of hurting people after becoming irritated. His thought processes were logical, clear, and goal-directed. He reported that a couple of times per month he saw an aura that was darker in color and that moved and pulsated, and he stated that he had some paranoid ideation. His affect was constricted, his mood was depressed, he had some insight, and his judgment was moderately impaired. The VA physician diagnosed rule out PTSD and alcohol abuse and assigned a GAF score of 55. A December 2007 VA treatment record shows the Veteran was easily startled, jumpy, and short-tempered. The Veteran got angry easily and felt anxious that something was going to happen. The Veteran reported that three months prior he had nightmares of Vietnam three times in one week, but that he had not had a nightmare for one month. He reported some avoidance of watching television news about Iraq and had gone through periods of depression, with the last episode occurring last week and the longest episode lasting two to three days with feelings of worthlessness. The Veteran denied a history of hospitalizations, suicide attempts, and violence. On examination, the Veteran was cooperative, euthymic, and irritable, with good hygiene and normal speech. His thought processes were logical, and there was no evidence of suicidal or homicidal ideations. No psychosis was present, and his insight and judgment were intact. The assessment was PTSD by history and co-morbid depression. The VA physician assigned a GAF score of 69. In February 2008, the Veteran reported that his PTSD symptoms began seven years ago and had progressively worsened. He described nightmares, irritability, low frustration tolerance, massive depression, loneliness, feelings of worthlessness, and paranoia. He also reported flashbacks of Vietnam. The Veteran described having a good relationship with his wife, daughter, and son. He stated that his leisure time and interests included watching television and occasionally going to the movies, although he had lost interest in most other things, to include fishing, since his PTSD symptoms had increased. On examination, the Veteran was cooperative, and his mood was sad and anxious. He reported that he experienced hallucinations that involved shadows, disorientation where he would forget where he was driving, and immediate memory impairment. The Veteran also stated that he had difficulty concentrating and that his thought content included inadequacy and feelings of worthlessness. The Veteran also reported paranoid delusions. The VA psychologist diagnosed PTSD and alcohol abuse and assigned a GAF score of 55. The VA psychologist reported that the Veteran's highest GAF score in the past year was 50. A March 2008 VA mental health note reflects that the Veteran reported experiencing a low level of sadness for the past two weeks, daily anxiety, being always irritable, frustrated with his hygiene, and some guilt. The Veteran denied suicidal ideations and homicidal ideations. He reported a decrease in the intensity and vividness of his nightmares. The Veteran was fully oriented, well-groomed, and his speech and language were normal. He reported his mood was stable, and his affect was congruent and reactive. His thinking was goal-oriented, and he was anxious, but he denied suicidal and homicidal ideations and abnormal perceptual experiences. His attention span, memory, and concentration were fair. His insight and judgment were preserved. The VA psychologist assigned a GAF score of 55. The Veteran underwent VA examination in April 2008. The VA examiner reviewed the Veteran's claims file. The Veteran reported having problems getting up in the middle of the night, hating crowds, and having problems with people making him angry, although he was now more tolerant of people. He also noted that he had bad dreams. On examination, the Veteran was cooperative, neatly dressed and groomed, and not withdrawn or agitated. He denied any hallucinations. There was no evidence of altered level of consciousness. The Veteran was not able to recall six digits backwards. His long-term memory was good, and his concentration was unimpaired. He denied any obsessive thinking or compulsive behaviors. The Veteran described his mood as both anxious and irritable, and his affect was one of anxiety. He denied any suicidal or homicidal ideations and denied a history of suicidal or assaultive behaviors. There was no evidence of an impaired capacity for proper hygiene. The Veteran reported feelings of inadequacy and worthlessness part of the time and feelings of hopelessness once in a while. He denied having any libido or interest in hobbies. He was irritable but denied any tearfulness. The Veteran also denied any symptoms of mania or panic attacks. He reported having a close relationship with his wife, daughter, and youngest brother. He stated that he had one friend. He did not belong to any groups or clubs, did not know any of his neighbors, and stated that police irritated him. The Veteran was easily distracted and often started tasks but would not complete them. He reported persistently re-experiencing traumatic events in the form of intrusive and distressing recollections approximately once a month, distressing dreams once a month, and flashbacks once every six months. Loud noises caused intense psychological distress, and the Veteran had persistent avoidance of stimuli associated with the trauma. The Veteran also avoided certain activities and situations, particularly crowds and small rooms. Numbing of general responsiveness took the form of markedly diminished interest in significant activities and feelings of detachment. He had a restricted range of affect. Persistent symptoms of increased arousal included difficulty sleeping, irritability, hypervigilance, and an exaggerated startle response. The VA examiner diagnosed PTSD, major depressive disorder, and alcohol abuse in early remission. The VA examiner assigned a GAF score of 55 and found that the Veteran's symptoms had a major, negative impact on his ability to obtain and maintain physical or sedentary employment and caused significant to major interference with his social functioning. An April 2008 VA treatment record indicates the Veteran reported that after his last weekly discussion with a clinical psychologist, he started thinking about all of his experiences and traumas. As a result, he could not concentrate and was anxious, irritable, and restless. The Veteran was fully oriented, well-groomed, and his speech and language were normal. He was anxious discussing traumatic experiences, denied suicidal and homicidal ideations, and denied any abnormal perceptual experiences. His attention span, memory, and concentration were fair, and his insight and judgment were preserved. The VA psychologist assigned a GAF score of 55. In June 2008, an outpatient mental health treatment plan shows the Veteran's PTSD symptoms included restlessness, sleep disturbances, flashbacks, intrusive memories, trust issues, and hyperarousal. A December 2008 mental health note reflects that the Veteran was showing improvement in his PTSD symptoms as they were less intense and less frequent, although he was still experiencing depression and anxiety. A February 2009 VA treatment record indicates the Veteran's PTSD symptoms had decreased, although he continued to have re-experiencing symptoms, hyperarousal, and avoidance. The Veteran also continued to feel irritable, sad, and anxious. VA treatment records dated in March, April, and May of 2009 show the Veteran was fully oriented, well-groomed, and his speech and language were normal. He was anxious discussing traumatic experiences, denied suicidal and homicidal ideations, and denied any abnormal perceptual experiences. His attention span, memory, and concentration were fair, and his insight and judgment were preserved. A June 2009 VA treatment record demonstrates an assigned GAF score of 50. A July 2009 VA treatment record reflects that the Veteran had high moods with psychosis, fast driving, depression without psychosis, suicidal thoughts, and thoughts to harm his co-workers. He had no acute symptoms of PTSD with flashbacks or loss of behavior control, prominent detachment, or hyperarousal. The VA physician diagnosed PTSD, bipolar type mood disorder due to PTSD, and alcohol dependence and assigned a GAF score of 40. An additional July 2009 VA treatment record indicates the Veteran was fully oriented, well-groomed, and his speech and language were normal. He was anxious discussing traumatic experiences, denied suicidal and homicidal ideations, and denied any abnormal perceptual experiences. His attention span, memory, and concentration were fair, and his insight and judgment were preserved. The Veteran reported that his mood was depressed, anxious, and irritable, but that it had improved since his vacation. He also reported having premonitions. An August 2009 VA mental health note shows the Veteran reported that his mood was mellow and that he continued to work two jobs. He had better quality sleep, and he denied mood swings, excessive energy, and racing thoughts since starting his medication. He also denied nightmares and intrusive thoughts. His hypervigilance, although still present, was better, and he also reported avoidance. He denied impulsivity but reported that during the previous week he had seen a shadow in his peripheral vision. He denied suicidal and homicidal ideations and hallucinations. The Veteran was fully oriented, well-groomed, and his speech and language were normal. His thinking was goal-oriented, and his attention span, memory, and concentration were fair. His insight and judgment were preserved. A September 2009 VA treatment record shows the Veteran reported feeling very good, with no suicidal thoughts. An additional September 2009 VA treatment record reflects that the Veteran reported his mood was mostly stable, with mild cycling, and that it was easier for him to focus. He denied auditory hallucinations but stated that he saw shadow people in his peripheral vision. He denied suicidal thoughts, anxiety, and panic. On examination, he was well-groomed, polite, shy, and quiet, with a good mood. His speech was clear, and his thought processes were linear. His delusions involved a belief that he could predict the future, and he denied suicidal and homicidal ideations. He was alert and oriented, and his attention, concentration, insight, and judgment were adequate. He denied panic attacks, acute PTSD symptoms, and detachment. The diagnosis was PTSD, bipolar type mood disorder due to PTSD, compulsive behavior due to PTSD, and alcohol dependence in remission. The VA clinical nurse specialist assigned a GAF score of 50. The Veteran underwent additional VA examination in December 2009. The Veteran reported intrusive re-experiencing of memories of Vietnam, including disturbing nightmares. However, the Veteran reported that the nightmares occurred much less often with his medication. He also indicated that he continued to have symptoms of avoidance, detachment, and isolation. The Veteran was also quite hypervigilant, but he denied any recent panic attacks. On examination, the Veteran was neatly dressed, groomed, appropriate, cooperative, and made eye contact. He was somewhat tense, and his speech and thought processes were normal. The Veteran did not clearly indicate any delusional processes or hallucinations. When he was anxious and very hypervigilant, he tended to see shadows out of the corner of his eye. The Veteran denied suicidal ideations, although he reported frequently having thoughts of violence toward people. The VA examiner diagnosed PTSD, bipolar mood disorder, not otherwise specified, and alcohol dependence, in early full remission. The VA examiner assigned a GAF score of 55 and found the Veteran continued to present with symptoms of PTSD. He continued to work full-time and had found that with consistent treatment and medication, he was much better able to manage his temper. He had improved his relationship with his wife; however, he remained quite impaired, especially in his social functioning. A December 2009 mental health note indicates the Veteran had prominent detachment, irritability, and hypervigilance. His mood cycles were mild, and he denied severe depression, suicidal thoughts, and hypomania. The Veteran continued to have premonitions and compulsive organizing. The VA clinical nurse specialist assigned a GAF score of 51. In his January 2010 substantive appeal, the Veteran reported that when he was first examined for his PTSD, the VA examiner found his symptoms warranted a moderate rating. The Veteran stated that he saw his mental health provider weekly and twice a month due to the provider's workload. The Veteran asserted his rating should reflect moderate symptoms due to the physical and mental trauma he had suffered since active duty. A March 2010 mental health note shows the Veteran had suicidal ideations and auditory and visual hallucinations the previous month, which were more severe and included seeing shadow people. The Veteran reported increased PTSD symptoms, to include anxiety, isolation, poor concentration, and difficulty sleeping, and he stated that he had mild racing thoughts. He denied premonitions but kept standard daily routines. On examination, the Veteran was well-groomed, pleasant, and mildly anxious. His mood was good, his speech was clear, and his thought processes were linear. He had auditory hallucinations when severely depressed but denied delusions. His attention, concentration, insight, and judgment were adequate. The VA clinical nurse specialist assigned a GAF score of 50 and found the Veteran had prominent avoidance, detachment, and hyperarousal. He had chronic obsessive/compulsive disorder but was functioning at home and at work. In April 2010, the Veteran reported improved anxiety symptoms, sleeping well, and decreased intrusive thoughts. He denied nightmares and flashbacks but reported detachment. He reported that his irritability and hypervigilance had improved. His mood was stable, and he denied suicidal ideations. The Veteran reported chronic delusions. The VA clinical nurse specialist assigned a GAF score of 53 and noted that the Veteran had no friends, with a mild psychosis, and was functioning. VA treatment records in August and September 2010 show the Veteran had a history of manic episodes, depression with suicidal ideation, and premonitions. He also had obsessive-compulsive disorder symptoms with excessive organization. He denied obsessive thoughts but had a history of panic attacks with severe hypervigilance and paranoia. On examination, the Veteran was well-groomed and pleasant, with a slightly restricted affect. His mood was a little up, his speech was clear, and his thought processes were linear. He denied hallucinations but reported delusions that involved thought broadcasting and hearing. The Veteran denied suicidal and homicidal ideations, he was alert and oriented, and his insight and judgment were adequate. The Veteran continued to report flashbacks and feeling irritable, although his hyperarousal symptoms were improving. The VA clinical nurse specialist assigned a GAF score of 51 and found the Veteran had moderate to severe PTSD, bipolar due to PTSD, and manic/mixed states with increased delusions without lithium. A November 2010 VA treatment record demonstrates a GAF score of 51. The Veteran reported that his mood was more stable and calmer. He continued to report broadcasting/hearing delusions when in public, and his auditory hallucinations had decreased to a few times per week. He denied depression, suicidal ideations, and impulsive/risky behavior. The Veteran reported severe PTSD flashbacks but denied a loss of temper, irritability, and loss of behavior control. He continued his organizational routines but no longer checked his tools. In December 2010, the Veteran reported that he felt much better and had no complaints of depressed mood, anxious affect, or disorganized or disturbed thoughts. He reported no auditory hallucinations or other perceptual distortions and denied suicidal ideations. The Veteran denied flashbacks, intrusive thoughts, and checking his tools. An additional December 2010 VA treatment record shows a GAF score of 51. In February 2011, the Veteran reported feeling good with no problems and no complaints of depressed mood, anxious affect, and disorganized/disturbed thoughts. He reported no recent flashbacks and no intrusive thoughts. He continued to have organizational routines and re-checked things two to three times. He was well-groomed and pleasant, with a slightly restricted affect. His speech was clear, his thought processes were linear, and he did not have any auditory hallucinations. The Veteran had acute delusions without lithium but denied suicidal and homicidal ideations. He was alert and oriented, and his insight and judgment were adequate. A March 2011 VA treatment record reflects a GAF score of 55. He reported milder PTSD symptoms and denied recent flashbacks. The Veteran reported that his anxiety had improved. VA treatment records dated in April and May of 2011 reflect similar findings. In June 2011, the Veteran was well-groomed, very pleasant, and his affect was full. His speech was clear, and his thought processes were linear. He denied hallucinations, delusions, suicidal and homicidal ideations, and he was alert and oriented. His attention and concentration were adequate, and his insight and judgment were intact. An additional June 2011 VA treatment record shows the Veteran reported restlessness, increased dreams, and irritability. He had also engaged in compulsive behavior and had been re-checking items as a medium to reduce his anxiety. He denied any auditory hallucinations and other perceptual distortions, suicidal ideations, and bouts of mania and depression. He denied recent flashbacks and intrusive thoughts. In August 2011, the Veteran underwent additional VA examination in connection with his claim. The VA examiner assigned a GAF score of 55 and opined that the Veteran's disability resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, with normal routine behavior, self-care, and conversation. The VA examiner found the Veteran had no relevant changes in his social, marital, family, or occupational history since his last examination. The Veteran's symptoms included anxiety and suspiciousness, and he noted an improvement in his mood. The Veteran last experienced nightmares or re-experiencing symptoms close to one year prior, and he denied symptoms of avoidance. The Veteran reported mild irritability, some hypervigilance, and some hyperstartle response. He denied current symptoms of mania and depression and reported feeling happy. As a result, the VA examiner found the Veteran did not meet the criteria for a diagnosis of PTSD at that time, but rather found that a diagnosis of bipolar disorder not otherwise specified was appropriate. The VA examiner determined that the Veteran's psychiatric symptoms had improved since his last examination, particularly in the past year. Given the above record, the Board concludes that the evidence demonstrates that throughout the pendency of the appeal, the Veteran's PTSD with bipolar mood disorder, not otherwise specified, was manifested by occupational and social impairment with reduced reliability and productivity. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.130, Diagnostic Code 9411. Initially, the Board notes the Veteran experienced symptoms that are not listed in the rating criteria, and as a result, the Board has considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with deficiencies in most areas. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The evidence demonstrates that the Veteran's PTSD with bipolar mood disorder, not otherwise specified, was manifested by restricted affect, sleep impairment, nightmares, flashbacks, depression, anxiety, isolation, avoidance, exaggerated startle response, hypervigilance, hallucinations, delusions, and obsessive/compulsive behavior. The Board notes the Veteran's reports of avoiding groups and social settings, only having a few acquaintances and no friends, and feeling lonely and isolated. In addition, the evidence shows the Veteran had some impaired judgment, difficulty concentrating, difficulty being in public due to auditory hallucinations, and difficulty with co-workers due to paranoid ideations. Further, the Board affords significant value to the December 2009 VA examiner's opinion that although the Veteran continued to work full-time and had improved his relationship with his wife, he remained quite impaired in his social functioning. Further, the evidence shows the VA clinical nurse specialist found the Veteran had moderate to severe PTSD. Finally, the Board acknowledges that the most recent VA examiner in August 2011 opined that the Veteran's service-connected disability resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, with normal routine behavior, self-care, and conversation. In this case, however, the Board finds the years of VA treatment records demonstrating more severe symptoms carry greater probative value than the August 2011 VA examination findings and opinion. Throughout the pendency of the appeal, VA treatment providers assigned GAF scores ranging from 40 to 69, indicating a range of mild symptoms, such as depressed mood and mild insomnia, to serious symptoms, such as severe obsessional rituals and serious impairment in social or occupational functioning. Here, the Board finds the Veteran's specific symptoms are most accurately reflected by the middle range of GAF scores assigned, which represent moderate difficulty in social and occupational functioning. Specifically, the evidence reflects symptoms of depressed mood, restricted affect, a few friends, and difficulty dealing with co-workers. While there were times wherein the Veteran's GAF score improved or worsened, the manifested symptoms remained largely constant. As such, the Board concludes that the evidence as a whole more nearly approximates the criteria for a 50 percent disability rating for the entire pendency of the appeal. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411; see Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the Board finds that a rating in excess of 50 percent is not warranted for the Veteran's service-connected PTSD with bipolar mood disorder, not otherwise specified. The evidence of record does not reflect occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. Specifically, the evidence does not demonstrate that any suicidal ideations, hallucinations, delusions, or obsessional rituals interfered with routine activities or that the Veteran had speech intermittently illogical, obscure, or irrelevant. The Veteran has not reported near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, and the evidence does not reflect neglect of personal appearance and hygiene. The Board acknowledges the April 2008 VA examiner's findings that the Veteran's symptoms had a major, negative impact on his ability to obtain and maintain physical or sedentary employment and caused significant to major interference with his social functioning. However, the Board finds this opinion inconsistent with the other evidence of record, especially considering that the Veteran has been able to maintain steady employment throughout the pendency of the appeal. In addition, the Veteran has reported good interpersonal relationships with his wife, children, and one sibling. Further, several VA treatment records reflect that despite the Veteran's moderate to severe PTSD symptoms, he was functioning at home and at work. In this respect, the Board is cognizant that the Rating Schedule is meant to reflect the average impairment of earning capacity resulting from service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. For these reasons, the Board finds that the criteria for a disability rating of 50 percent, but no more, for PTSD with bipolar mood disorder, not otherwise specified, have been met throughout the pendency of the appeal. 38 C.F.R. § 4.130. 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, 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. 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 Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the rating assigned herein inadequate. The Veteran's service-connected PTSD with bipolar mood disorder, not otherwise specified, is evaluated as a psychiatric disability, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. Thun, 22 Vet. App. at 115; see also 38 C.F.R. § 4.130, Diagnostic Code 9411. Throughout the pendency of the appeal, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity, due to such symptoms as restricted affect, sleep impairment, nightmares, flashbacks, depression, anxiety, isolation, avoidance, exaggerated startle response, hypervigilance, hallucinations, delusions, and obsessive/compulsive behavior. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are contemplated by a 50 percent disability rating. A rating in excess of 50 percent is provided for certain manifestations of a psychiatric disability, but the medical evidence demonstrates that those manifestations are not present in this case. The criteria for the 50 percent disability rating assigned herein more than reasonably describe the Veteran's disability level and symptomatology, and therefore, the schedular evaluation is adequate, and no referral is required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). By this decision, the Board has found that a 50 percent rating for PTSD with bipolar mood disorder, not otherwise specified, is warranted throughout the pendency of the appeal. However, because occupational and social impairment with deficiencies in most areas is not established, the preponderance of the evidence is against the assignment of a 70 percent rating. Therefore, there is no doubt to be resolved, and a rating in excess of 50 percent is not warranted. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial disability rating of 50 percent, but no more, for PTSD with bipolar mood disorder, not otherwise specified, is granted. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs