Citation Nr: 1320812 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 08-29 605 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for the period from June 8, 2005, to January 23, 2013, for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial evaluation in excess of 70 percent for the period on or after January 23, 201, for PTSD. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Postek, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In that decision, the RO granted service connection for PTSD and assigned a 30 percent disability rating effective from June 8, 2005. A Board hearing was held before the undersigned Veterans Law Judge in February 2012. A transcript of the hearing is of record. At the hearing, the Veteran also submitted additional evidence with a waiver of the RO's initial consideration. The Board remanded the case for further development in December 2012. That development was completed, and the case has since been returned to the Board for appellate review. During the pendency of the appeal, a February 2013 rating decision increased the disability rating for the Veteran's PTSD to 70 percent effective from January 23, 2013. While the Veteran has been granted an increased evaluation, this rating does not represent the highest possible benefit, and therefore, this issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board has recharacterized the issues accordingly. In addition to the paper claims file, there is a Virtual VA electronic file associated with the Veteran's case. A review of the documents in the electronic file reveals that some of those records are non-duplicative of those in the paper claims file, to include evidence of the Veteran's ongoing VA treatment. However, those records were obtained and considered by the RO prior to the issuance of the most recent supplemental statement of the case in February 2013. In addition, the Veteran submitted a statement that same month indicating that he waived the RO's initial consideration of any additional evidence submitted. Therefore, the Board finds that there is no prejudice in proceeding with consideration of the evidence in the Virtual VA file. FINDINGS OF FACT 1. For the period from June 8, 2005, to January 23, 2013, the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas. 2. For the period beginning on January 23, 2013, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 50 percent, but no higher, for PTSD have been met for the period from June 8, 2005, to January 23, 2013. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an initial evaluation in excess of 70 percent for PTSD for the period on or after January 23, 2013, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A (West 2002); 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing her or his entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Nevertheless, the Veteran in this case is challenging the initial evaluation assigned following the grant of service connection for PTSD. In Dingess, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8-2003 (December 22, 2003). Thus, because the notice provided before service connection was granted was legally sufficient, VA's duty to notify has been satisfied with respect to the issue of entitlement to higher initial evaluation for PTSD. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available VA medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. He has not identified any available, outstanding records that are relevant to the claim being decided herein. Moreover, the record includes written statements provided by the Veteran and his representative, as well as a transcript of the February 2012 Board hearing. The Veteran was also afforded VA examinations in December 2005 and January 2013 in connection with his current claim. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations in this case are adequate, as they are predicated on a review of the Veteran's medical history as well as on an examination and fully address the rating criteria that are relevant to rating the disability in this case. The Board does observe that it is unclear if the December 2005 VA examiner reviewed the claims file; however, the examiner did review the Veteran's own reported medical history and complaints and performed an examination that addressed all of the rating criteria. Indeed, the Court has held that the relevant focus is not on whether a clinician had access to the claims file, but instead on whether the clinician was "informed of the relevant facts" in rendering a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Moreover, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disability since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). As previously noted, the Veteran testified at a hearing before the undersigned Veterans Law Judge in February 2012. The Veterans Law Judge clearly set forth the issue to be discussed, sought to identify pertinent evidence not currently associated with the claims folder, and elicited further information as to the dates and locations of treatment when appropriate. The hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony and questioning by his representative, demonstrated his actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that VA complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). VA has further assisted the Veteran throughout the course of this appeal by providing him with an SOC and an SSOC, which informed him of the laws and regulations relevant to his claim. The Board concludes the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claim and did in fact participate. Washington v. Nicolson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Law and Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, as in this case, where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Separate ("staged") ratings may be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran's service-connected PTSD is currently assigned a 30 percent disability rating for the period from June 8, 2005, to January 23, 2013, and a 70 percent disability rating thereafter, pursuant to the Rating Schedule at 38 C.F.R. § 4.130 (General Rating Formula for Rating Mental Disorders), Diagnostic Code 9411. Under this criteria, a 30 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when the psychiatric disorder results in 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the psychiatric disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be an exhaustive list. The Board need not find all or even some of the symptoms to award a specific rating. If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002); Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004) (agreeing with Court's interpretation in Mauerhan). In addition, the Federal Circuit recently stated that evaluation under § 4.130 is "symptom-driven" and that "a veteran may only qualify for a given disability rating under [this criteria] by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that § 4.130 "requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In assessing the degree of psychiatric disability, GAF (Global Assessment of Functioning) scores are for application and reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV)); see also 38 C.F.R. §§ 4.125, 4.130 (incorporating DSM-IV in the rating schedule). However, a GAF score assigned in a case is not entirely dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In this case, a December 2004 VA treatment record shows that the Veteran had experienced combat flashbacks in the past month and reported a social history of drinking a six-pack of beer three to four times each week. In his June 2005 claim, the Veteran indicated that he was fired from his job of ten and a half years in May 2005, which was the sixth time he had been fired from a job since returning from Vietnam. He reported that he had been a member of an organization for Vietnam veterans since 1988, attended annual reunions, and participated as an officer. He stated that meeting with other veterans and attending events was helpful to him. In a July 2005 written submission, the Veteran's private psychologist, Dr. G.D. (initials used to protect privacy) stated that he had met with the Veteran on three occasions beginning in 2003 for difficulty sleeping due to flashbacks and depression. Upon further evaluation, Dr. G.D. noted that it was clear the Veteran had been troubled by consistent nightmares for several years, as well as some depressive symptoms. He provided a diagnosis, to include PTSD, and offered treatment, but the Veteran declined. Dr. G.D. also indicated that, in his opinion, the Veteran had known that he suffered from PTSD for a long time but avoided treatment because of pride, a lack of willingness to explore his trauma, and being hesitant to be identified as a patient. The Veteran was afforded a VA examination in December 2005 during which he reported having recurring symptoms beginning shortly after service, including trouble sleeping with frequent nightmares, intrusive thoughts, flashbacks, persistent difficulty concentrating, hypervigilance, avoidance behavior, and being easily startled. He reported that he worked in a number of sales jobs following service and had good relationships with his supervisor and co-workers, but state that he was fired from these jobs. He also reported that he only worked to stay busy. Socially, the Veteran indicated that he was married and had a good relationship with his wife and child, as well as his brother and sister. He was also active with a group of local veterans. Aside from his evaluation with Dr. G.D., he reported no previous contact with a mental health provider. The examiner noted that the Veteran was quick to admit that he started using alcohol following service to get sleep, which was a habit that continued to the present day. On mental status examination, the Veteran's behavior, appearance, and hygiene were appropriate, and his orientation, communication, and speech were within normal limits. His affect and mood were abnormal with disturbance of motivation and mood. There were no panic attacks or obsessive rituals, and there was no history or observation of delusions or hallucinations. The Veteran's thought process was appropriate, his judgment was not impaired, and his abstract thinking and memory were within normal limits. Suicidal and homicidal ideations were absent. Following an examination, the Veteran was diagnosed with PTSD. The examiner noted that the Veteran's alcohol abuse was secondary to his PTSD, as he attempted to deal with anxiety provoked by the memories of war. Based upon the demonstrated symptomatology, the Veteran was assigned a GAF score of 48. The examiner noted that the Veteran did not mentally have difficulty performing activities of daily living, but he did have difficulty establishing and maintaining effective work and social relationships due to his PTSD. In a January 2007 written statement, the Veteran's wife recalled symptoms that he had experienced over the years that had remained part of his behavior since returning from service, including emotional distancing from her, near-daily excessive drinking, not completing projects, chronic difficulty sleeping, and his lack of motivation to get another job. She noted his heavy interest in war-related items and events and indicated that that he had no difficulty showing his emotions, but only to his veteran buddies. She also stated that she was able to get him a job with the Cobb Chamber of Commerce several months earlier. A September 2009 VA treatment record shows that the Veteran continued to be employed by the Cobb Chamber of Commerce. The Veteran first sought regular mental health treatment through the VA Medical Center (VAMC) in Atlanta in February 2010. During initial psychiatric assessment, he reported many of the same symptoms reported to the December 2005 VA examiner, such as sleep impairment with frequent nightmares, anxiety, avoidance behavior, difficulty concentrating at times, mood fluctuation, and daily alcohol use. He indicated that he had many friends through his various veterans associations. He provided a history of being let go from jobs several times for various reasons, but indicated that he had been working in his current job for the last four years. On mental status examination, the Veteran was alert and cooperative with fair eye contact. His mood and affect were anxious, his insight and judgment were fair, and his cognition was grossly intact. The provisional assessment, in pertinent part, was chronic PTSD with alcohol abuse, and a GAF score of 65 was assigned. The doctor noted that the Veteran's social and occupational dysfunction from any psychiatric disorder had been mild based on the reported history, as well as the Veteran's lack of prior treatment. In May 2010, the Veteran was seen by two different VA doctors for medication review and initial mental health treatment. The Veteran endorsed similar symptoms to those previously of record, to include frequent difficulty sleeping and flashbacks, as well as feeling emotional detachment from others and difficulty concentrating. With the medication he had started, his sleep was much better, and his mood was noted to be okay. He also reported that he was drinking less. On examination, the Veteran's mental health status was generally similar to that at the time of the February 2010 VA treatment with a report of a recent impairment for remembering names. The assessment was PTSD (noted with alcohol abuse on one assessment), with plans to continue the current medications and begin therapy. Following the second assessment, a GAF score of 51 was assigned. Thereafter, the Veteran began ongoing mental health treatment through December 2011 at the VAMC in Atlanta. During this treatment, he reported ongoing difficulties with nightmares that were not helped much by medication. He also reported his continued social support through a small group of fellow Vietnam veterans. On mental status examinations, he was alert, cooperative, oriented, and appropriately groomed. His speech was normal, and he had a mildly dysphoric or euphoric mood and an appropriate affect that was constricted at times. There was no overt evidence of psychosis, and the Veteran denied having suicidal and homicidal ideations, plans, or intentions. In an October 2010 VA treatment record, the Veteran reported that therapy had helped some and that his troublesome memories and nightmares had lessened. In an January 2011 VA treatment record, the Veteran reported doing better overall with some dreams about Vietnam, but no focus on specific events. He also complained of an ongoing startle reaction. In a March 2011 appointment for medication review and minimal psychotherapy services, the Veteran reported that his mood and concentration were good and that his sleep was much better with medication. He reported flashbacks two to three times per week triggered by loud noises, with nightmares three times per week, and a reduced alcohol intake. In an April 2011 VA treatment record, the Veteran reported being let go from his job due to a business decision unrelated to his performance. Thereafter, in July 2011, he indicated that he was still unsure regarding his work future, but continued to enjoy being involved in the veteran organizations, as well as being able to spend more time with his family. While he was somewhat uneasy about inactivity at home thereafter, an October 2011 VA treatment record shows that he reported settling more easily into retirement. The Veteran continued mental health treatment at the Austell Community-Based Outpatient Clinic (CBOC) beginning in December 2011. During an initial assessment, his reported symptoms remained similar to those previously of record, including hypervigilance and nightmares. He reported that he always looked forward to the future. He drank two to three glasses of wine each night. On mental status examination, his results remained substantially similar from those of previous VA treatment in most areas with a dysphoric mood and restricted affect. A GAF score of 52 was assigned, which continued each time the Veteran saw this doctor for medication review and minimal psychotherapy services thereafter. See VA treatment records February, May, August 2012. Thereafter, the Veteran was assigned for ongoing mental health treatment beginning in January 2012 at which time he was noted to have chronic but stable PTSD and depressive symptoms. The Veteran reported that he was most troubled by his pervasive sense of affective numbing and an inability to tolerate having or expressing loving feelings for those closest to him, such as his son. He indicated that he was willing to work on this issue. On mental health examination, the Veteran continued to present with similar findings as those of his previous treatment at the VAMC with a recurring dysphoric mood. The ongoing treatment plan involved working on more cognitive and affect congruity as well as expanding his coping and leisure repertoire. During his February 2012 Board hearing, the Veteran testified that his PTSD had increased in severity since his VA examination in 2005. He testified that he experienced symptoms, including frequent nightmares, difficulty with complex commands (due in part to his dyslexia), some unprovoked irritability, hypervigilance, and problems with short- and long-term memory, such as forgetting appointments and when to pay bills. He also reported that he had a brother and sister that he did not see often, as they did not have much in common, although he stated they were close. His main social outlet was involvement in his numerous Vietnam veteran group activities. In a June 2012 VA treatment record, the Veteran reported being able to "finally get a good night's sleep" with medication. The Veteran was afforded a VA examination in January 2013 during which he reported symptoms, including trouble sleeping, nightmares, flashbacks, difficulty concentrating, diminished interest in activities, hypervigilance, avoidance behavior, irritability, emotional detachment from others, and being easily startled. Socially, aside from his veteran organization activities, his interpersonal interactions were largely limited to his spouse and adult son. He spent little time interacting with them. In regards to work, the Veteran retired in 2010. The examiner stated that the record suggested that the loss of his most recent job may have been a result of performance and/or interpersonal difficulties. The examiner noted that the Veteran had PTSD symptoms, including a depressed mood, anxiety, chronic sleep impairment, mild memory loss, a flattened affect, disturbances of motivation and mood, an inability to establish and maintain effective relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and emotional numbing and distancing. The examiner noted that the Veteran's reported reliance on the use of alcohol for "relaxation" was a symptom manifested in an effort to relieve PTSD-related anxiety. Following an examination, the diagnosis was PTSD. The examiner noted that, while recent treatment records indicated the presence of a depressive disorder, it was her determination that the manifestation of depressive symptoms was a function of PTSD-related distress, specifically, sleep disturbance, impaired concentration, and diminished interest in pleasure and activities. Based upon the demonstrated symptomatology, the Veteran was assigned a GAF score of 51. The examiner noted that the Veteran's symptoms were consistent with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. In a March 2013 statement, the Veteran indicated that he agreed with the 70 percent rating assigned, but wanted the rating to be effective the date of the filing of his substantive appeal in September 2008. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to an initial 50 percent evaluation, but no higher, for his service-connected PTSD for the period from June 8, 2005, to January 23, 2013. In addition, he is not entitled to an initial rating in excess of 70 percent on or after January 23, 2013. For the period from June 8, 2005, to January 23, 2013, the Veteran's disability picture, to include the severity, frequency, and duration of his symptoms and the resulting impairment of social and occupational functioning, is more consistent with a 50 percent disability rating. In this regard, the Veteran had a long-standing history of symptoms, including sleep disturbance with nightmares, flashbacks, anxiety, difficulty concentrating, disturbances of motivation and mood, and regular alcohol use shown in the record for dealing with PTSD symptoms. His nightmares resulting in sleep disturbance were shown to be very frequent, and when he was awake, he routinely reported the need to keep himself busy to avoid recurring flashbacks. The December 2005 VA examiner specifically found that the Veteran's PTSD symptomatology resulted in difficulty establishing and maintaining effective work and social relationships. The Board also notes the Veteran's social difficulties in assigning this rating, to include his difficulty in maintaining an effective relationship with his wife and child, as a result of his emotional distancing (as reported in VA treatment records and in his wife's written submission), as well as his regular use of alcohol to address symptoms (as observed by the December 2005 VA examiner). His wife further indicated that his drinking affected their relationship. However, the Board also notes that the Veteran was able to maintain an ongoing relationship with fellow veterans, to include significant participation in a number of veteran organizations. He also noted during VA treatment that, although he was not working, he enjoyed the opportunity to spend more time with family. He testified during the February 2012 Board hearing that he had always had a close relationship with his brother and sister and saw them several times a year. He opted not to see his brother often, although he lived nearby, because they did not share common interests. These examples reflect that the Veteran experienced some difficulty in maintaining some significant personal relationships due to his PTSD, even though he was able to establish and maintain solid social relationships otherwise. In regard to work, the record does reflect that the Veteran lost a number of jobs over the years following service. However, it is unclear as to whether he was laid off or fired from these jobs (or if he used these terms interchangeably) as a result of his PTSD symptoms. For example, the Veteran did report that he had been fired from his job in his June 2005 claim; however, he maintained that job for over a decade. His wife stated that he had been laid off of jobs in the past in her written submission. In addition, the Veteran reported during VA treatment that he was laid off of jobs for various reasons (February 2010 VA mental health intake), but had been at his present job for the past four years. He later reported in April 2011 that he had been let go as a result of a business decision unrelated to his performance. He also subsequently reported that he was fired and "between trying to find a job or . . . retired" during the Board hearing. See Bd. Hrg. Tr. at 8. In any event, this evidence and the overall resulting occupational impairment is more consistent with experiencing difficulty in establishing and maintaining effective work relationships, and most importantly, shows that the Veteran did not have an inability or equivalent impairment in establishing such relationships. Finally, the Board acknowledges the GAF scores of record that range between 48 and 65 during this period. A GAF score between 41 and 50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning. A GAF score between 51 and 60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning. A GAF score between 61 and 70 reflects some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. See 38 C.F.R. §§ 4.125, 4.130. In this case, the GAF scores assigned are but one factor for consideration in a rating. Overall, the symptoms demonstrated by the Veteran do not reflect an entire picture of behavior and level of impairment that is indicative of the high GAF score of 65 assigned during the initial VA mental health treatment intake in February 2010. The other GAF scores assigned during this period ranging from 48 to 52 are generally consistent with the moderate symptomatology contemplated in the 50 percent rating and support such a rating. Nevertheless, while considering the GAF scores of record as part of the overall social and occupational functioning picture, the Board finds the narratives contained in the treatment records and the VA examiner's explanations to be the most probative evidence of the Veteran's psychological symptomatology. In summary, the Board finds that the Veteran's overall disability picture is more appropriately contemplated by the criteria for a 50 percent rating during this portion of the appeal period, to include consideration of the Veteran's social and occupational functioning as discussed above. Overall, however, the Veteran has not demonstrated a level of impairment consistent with the 70 percent criteria, nor have the Veteran's symptoms caused occupational and social functioning in most of the areas referenced by the criteria referenced in the 70 percent evaluation. Mauerhan, supra, Vazquez-Claudio, supra. Indeed, on various mental health examinations throughout this time period, the Veteran was routinely well-groomed with normal speech, alert and oriented, cooperative, had fair insight and judgment, and routinely denied suicidal and homicidal ideations. He also indicated during the course of treatment that therapy and medication had helped reduce his symptoms, and he reported a decrease in his alcohol consumption. See, e.g., October 2010, January 2011, March 2011, June 2012 VA treatment records. In addition, a VA treatment records dated in February 2010 noted that he had only mild social and occupational impairment, and his treating doctor from the CBOC noted throughout his treatment in 2012 that he had chronic but stable PTSD. For the period beginning on January 23, 2013, the Board finds that the currently assigned 70 percent rating is appropriate, considering the Veteran's overall disability picture, to include the severity, frequency, and duration of his symptoms and the resulting impairment of social and occupational functioning as shown on the January 2013 VA examination. In this regard, the Board notes that this rating more than contemplates the Veteran's social and occupational impairment. Indeed, the symptomatology reported on the VA examination was largely similar to that throughout the remainder of the appeal with additional symptomatology related with the 70 percent criteria, such as difficulty in adapting to stressful circumstances and an inability to establish and maintain effective relationships. The one GAF score of 51 is indicative of moderate impairment. Moreover, the Veteran indicated his agreement with the assignment of this rating in his March 2013 written submission. In addition, for the entire appeal period, there is no indication in the record that the Veteran's overall disability picture is consistent with or functionally equivalent to a 100 percent rating. The record does not reflect, nor does the Veteran otherwise contend, that his symptomatology, discussed in detail above, resulted in total occupational and social impairment contemplated by this criteria at any time. For these reasons, the Board finds that the Veteran is entitled to a 50 percent initial evaluation for his service-connected PTSD for the period from June 8, 2005, to January 23, 2013, and his appeal is granted to that extent. The preponderance of the evidence, however, is against the assignment of a higher rating for that time period, as well as entitlement to an initial rating in excess of 70 percent on or after January 23, 2013, as these respective criteria have not been met or approximated based on the considerations discussed above. See Mauerhan, supra, Vazquez-Claudio, supra. As such, the benefit-of-the-doubt rule does not apply, and the claim is otherwise denied. Gilbert, 1 Vet. App. at 53. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's PTSD is so exceptional or unusual as to warrant the assignment of higher ratings on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id.; see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned disability ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Indeed, the current staged ratings contemplate the overall effect of all of his symptomatology on his occupational and social functioning. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected PTSD under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an initial evaluation of 50 percent, but no higher, for PTSD for the period from June 8, 2005, to January 23, 2013, is granted, subject to the provisions governing the award of monetary benefits. Entitlement to an initial evaluation in excess of 70 percent for the period on or after January 23, 2013, for PTSD is denied. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs