Citation Nr: 1321977 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 10-01 331 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Joseph R. Keselyak, Counsel INTRODUCTION The Veteran served on active duty from December 1966 to October 1968. This matter comes to the Board of Veterans' Appeals (Board) from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In a January 2010 rating decision, the RO granted the Veteran's claim for a total disability evaluation based upon individual unemployability (TDIU) based upon the combined effects of service-connected PTSD and prostate cancer. This issue is not before the Board. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). FINDINGS OF FACT 1. During the entire length of the appeal, the Veteran's PTSD has resulted in occupational and social impairment, with deficiencies in most areas, due to frequent suicidal ideation, near-continuous panic and depression, unprovoked irritability, difficulty in adapting to stressful circumstances, particularly in a work-like setting, and inability to establish and maintain effective relationships. He has not been shown, however, to have total occupational and social impairment. 2. The lay and medical evidence of record fails to demonstrate such an exceptional disability picture that the available 70 percent schedular evaluation for the Veteran's service-connected PTSD is inadequate. CONCLUSION OF LAW The criteria for the assignment of a disability rating of 70 percent for service-connected PTSD, but no greater, are met, and there is no evidence to warrant referral for consideration of a higher rating on an extraschedular basis. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(b), 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2011); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice should also address the rating criteria and effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, the RO provided the appellant satisfactory pre-adjudication notice by a letter dated in November 2008. Thus, the Veteran has been properly notified. VA also has a duty to assist the Veteran in substantiating his claim for benefits. Here, VA has obtained the Veteran's service treatment records, assisted him in obtaining evidence, afforded him physical examinations, and obtained medical opinions as to the severity of his PTSD. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The United States Court of Appeals for Veterans Claims (hereinafter "the Court") has held that 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 VA examinations obtained in this case in October 2007, December 2008, and May 2010 are adequate. They are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints, symptoms and history. The evidence dated since the most recent examination does not show a material worsening of the disability, such that a new examination would be required. Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue addressed in this decision has been met. 38 C.F.R. § 3.159(c)(4). VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Laws and Regulations Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. The VA schedule of ratings will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). 38 C.F.R. § 3.321(b)(1) provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, the veteran may be awarded a rating higher than that encompassed by the schedular criteria. According to the regulation, an extraschedular disability rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." Id. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. See 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. See 38 C.F.R. § 4.2 (2012); Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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). In addition, an appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates "staged ratings" where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). However, "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. VA 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 examination. 38 C.F.R. § 4.126(a). The general rating criteria used for evaluation of the Veteran's PTSD provides a 100 percent evaluation for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). The Veteran's disability is currently rated at 50 percent. 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 (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, DC 9411. A higher, 70 percent rating is warranted where the disorder is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: 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. Furthermore, with specific regard to the 70 percent rating, such rating "requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013) (emphasis added). The maximum 100 percent disability rating requires 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. It is noted that the "such symptoms as" language of the diagnostic code listed above means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. A Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score of 41-50 illustrates "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." A score of 51-60 represents "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co- workers)." In claims for VA benefits, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Facts and Analysis In evaluating the Veteran's PTSD in light of its history, the Board notes that he was afforded a VA psychiatric examination in October 2007. The examination report notes that the Veteran became alcoholic during and after his discharge from service. It also notes that during service he married and had a son. However, following his return from Vietnam, he had difficulties in his marriage and divorced. He reported an estranged and difficult relationship with his son that had persisted to present day. He related that following this divorce, that he had not re-married. At the time of the examination, the Veteran reported recurring and intrusive dreams and nightmares of his various stressors experienced during his Vietnam service. He did not sleep more than 3 to 4 hours and had distressing dreams about his comrades that were killed in Vietnam. He also outlined a history of a propensity for violence and that he would "fly off the handle quick" and "smash things." At this time, he continued to drink "six packs of beer" per day and spent his entire day, from 9:00 am to 9:00 pm in a bar. He was then working in construction and running heavy equipment. He had never had a DUI, but noted that he was cautious when drinking and driving. He denied any problems with his job, but related that he was not an outgoing person and that he missed a lot in terms of family and social obligations. Mental status examination showed that the Veteran was alert and oriented to time, place and person. He was casually dressed, often tearful and distressed, but showed good eye contact and responded appropriately to questions. He was casually groomed and had a dysthymic affect. He found it hard to talk about Vietnam, or anything else. He was not likely to speak to people until they spoke to him first. He felt tired a good deal of the time and regretted that his health had deteriorated to a point where he could not keep himself as busy as he would like to ward off his anxiety about his ex-wife and son. He related that he felt lonely when around other people and reiterated his history of alcohol abuse. He did not like to have people around him and disliked parties or socials, but denied a history of bar fights. He related that he liked to withdraw from others and to be passive in social situations. He tended to ruminate a lot about the loss of his buddies in Vietnam and the loss of his family. He showed signs of anhedonia and depression. He denied suicidal intent, but harbored suicidal thoughts. His thinking was linear and logical. Mini-mental state (MMSE) examination showed him able to handle attention, registration and daily problem solving. There were no psychotic signs and no serious cognitive impairment. He seemed to have adequate judgment, but lacked insight into the depth of his alcoholism and depression. He admitted that he had hit rock bottom and needed therapy. PTSD, moderate, with alcohol depression and alcohol dependency, in partial remission, were assessed. The examiner found that there was occasional decrease in work efficiency and intermittent periods of cognitive impairment. He also noted that the Veteran showed reduced reliability and productivity due to PTSD signs. MMPI2 results showed depression, a high level of social introversion and anxiety. It was noted that the was too depressed and fatigued to maintain his current job. A GAF score of 65 was assigned. A November 2007 VA psychology note documents continued complaints of PTSD and expressions of regret over his failed marriage and strained relationship with his son. It also documents a diagnosis of PTSD, severe, with depression. Subsequent VA psychology notes reveal similar findings. A January 2008 VA consultation report notes that the Veteran completed some college and was employed in construction, but had not worked in the past 2 to 3 months. He complained of back pain and noted a history of back surgery. He was alert, oriented and understood the purpose of the evaluation. His speech was normal in rate and content. His affect was pleasant. He was appropriately dressed and mannered. He had no gross cognitive deficits. His history of divorce was noted, although he was then currently living with a companion. His relationship with his son was strained. He often spent time visiting his mother, who lived in n assisted living facility. He used to enjoy golfing and horseback riding, but did not participate in either activity due to back pain. He ranked his social functioning and his mental health as average. The Million Behavioral Health Inventory was administered and he produced a coping style characterized as inhibited. It was noted that higher scorers with this style tended to be hesitant with others and are often shy and ill-at-ease. He did not then endorse any concern over recent stress, future despair or somatic anxiety. A May 2008 VA treatment record documents a 45 minute session of cognitive therapy and similar impressions as noted above. It also documents that the Veteran had a diagnosis prostate cancer and was considering chemotherapy, and that he had lost a sister to cancer. PTSD, severe, with depression, was assessed at this time. In furtherance of substantiating his claim, the Veteran submitted a July 2008 letter from his significant other. She outlined several instances where the Veteran became violent, particularly towards property. She also related occasions on where he "blacked out" and that he tended to be a negative person and that there was little that gave him pleasure. She related that one of the only things that seemed to give the Veteran pleasure was interaction with their dogs. She also related that on more than one occasion, she witnessed the Veteran engage in Russian roulette. The Veteran also submitted a letter from his ex-girlfriend. In the letter she too related a history of violence and witnessing the Veteran play Russian roulette. She related that due to his violence and temper they broke up, but had been best of friends ever since. An early December general VA psychology note documents that the Veteran had a shocking experience when he found his friend dead after he had committed suicide. The Veteran was very distressed, but was then recovering and making progress. He was noted as remaining with suicidal thoughts, but had contracted for safety with a VA psychologist. In December 2008, the Veteran was again afforded a VA examination. In terms of past psychiatric history, the examiner noted that it was significant for no inpatient psychiatric hospitalization or psychotropic medication trials. A history of alcohol dependence was noted and that the Veteran continued to drink periodically, although he had cut down significantly. He had no legal history and had been seeing a VA psychiatrist for counseling on an on-and-off basis. The examination report documents that he continued to live with his girlfriend and related that he got along with her fairly well. He did, however, relate that he had times when he was moody and would bring her down. He related that they enjoyed spending time with each other and their dogs. He went shopping with her and tried to spend time with her. He related that she was very laid back and that they seemed to be able to have a good balance between times when he needed to be left alone and that they had seemed to have the right mix in terms of their relationship as a whole. He related feeling very close to her and that he loved her, and that he knew she loved him. He felt that she was very supportive of him. His past history of marriage and divorce was noted. It was also noted that his present relationship was pretty good, although he had trouble maintaining relationships in the past. He also related having other support in his life, including his sister, whom he spoke to monthly. He also reported that his other sister had passed away from cancer and that he recently had some very significant problems in that his best friend passed away from suicide around Thanksgiving. The Veteran reported, generally, that he had been able to make some close friends and that he had some pretty close friends, but that his deceased friend was, by far, his best friend. He related that at one point he had suicidal thoughts himself, but was able to dismiss them and that there was no acting out or problems in regard to the suicidal thoughts. The examiner noted that his suicidal thoughts had passed and that he was able to contract for his safety. There was no intent, plan, wish or goal to harm himself at the time of the examination. In terms of recreation, he spent time with his girlfriend and did work around the house. He owned his own excavating company and had one employee besides himself. He related that they had not done any real work over the past couple of months as things had been very quiet. He had owned this business for about 20 years and related that he liked working by himself and had done reasonably well, although the company never took off and had only been a small business. Generally, he sounded like he was content with his business. At the time of the examination, the Veteran related continued problems with Vietnam and that he thought about it quite frequently. When he thought about it, he related becoming distressed, anxious, and often depressed. He admitted that the intrusive thoughts were bothersome to him and were most difficult when he was not distracted. He described clearly having a lot of psychological distress and, at times, developing some physiologic aspects in the form of panic feelings, but nothing of great significance. He continued to complain of arousal problems and significant problems with sleep. He related feeling very irritable and clearly had rage attacks, although most of the rage attacks occurred in the context of using alcohol. He did have some startle responses, but they seemed mild in severity. He had a minimal amount of hypervigilance problems and described being very observant of things and feeling hyper at times. His concentration was impaired, but only to a mild degree. He had some avoidance symptoms. He related that he kept his feelings and thoughts to himself and that he had a fair amount of feelings of estrangement from others. He did not feel like he could fit in and was uncomfortable around other people. He related being better on-on-one. He did not feel very confident in terms of his ability to connect or feel thoughts of love. He did not exhibit a sense of a foreshortened future, although he was a bit of a pessimist and tended to be negative. He found it difficult to enjoy things and always had low grade depressive type feelings. He possibly had some psychogenic amnestic symptoms and had difficulty remembering some of the traumatic events, but a lot of this was felt to possibly be within normal limits. He had a lot of blackout periods with rage attacks and things in the past, but most of these were felt to likely be related to alcohol use. He did not have any major issues with mania or mixed episodes. He had never been psychotic. He had some generalized anxiety-type symptoms as a worrier. He had some obsessive-compulsive type of symptoms, e.g. feeling the need to wash his hands after a handshake, but it did not rise to the level of obsessive-compulsive disorder. Impulse control problems were present, but were mostly related to alcohol. Mental status examination revealed that the Veteran arrived on time for the evaluation. He was casually dressed and groomed, and appeared to be in no acute distress, but did display a restricted affect throughout most of the session. Although his affect was broad-ranged, he tended to have a restricted flavor to his affect and an anxious edge to it. He had pretty good eye contact and was a reliable historian. Speech was within normal limits and there were no current suicidal or homicidal thoughts, and no intent, plan, wish or goal to harm himself. He was generally alert throughout the session and did not show any signs of substance-related changes. His thought process was clear, coherent, goal-directed and logical. His thought content was free of obsessions, compulsions, delusions or hallucinations. In terms of sensorium, he was alert and oriented. There was no evidence of any major concentration or memory disturbances. Judgment and insight were pretty good. He was found able to manage his funds. The examiner assessed PTSD and alcohol dependence in partial remission. A GAF score of 55 to 65 was assessed. A January 2009 VA general psychology note documents that the Veteran had been having serious social and vocational impairments that were not articulated as they should have been in the last two VA examinations. The note documents that the VA psychologist did not feel that they adequately emphasized the impairments, poor sleep, numbing of feeling and suicidal ideation the Veteran had. The psychologist noted, however, that the reports were similar in pointing out how the Veteran was increasingly disturbed by his symptoms and unable to work on a full-time basis. The psychologist remarked that the symptoms of PTSD were severe enough to cause social and vocational impairments and that the Veteran had been working part-time only on account of his pain and stress, and that he had not worked at all since September 2008. The Veteran related feeling more stressed out on account of the radiation he was then taking for prostate cancer. The Veteran related that he felt overwhelmed by his deteriorating medical condition and wondered why these symptoms were not taken into consideration. He then asked for psychiatric medication to help. Of record is a February 5, 2009, general psychiatry note documenting a chief complaint of "not taking any medicine for anxiety and depression." At this time, the Veteran reported continued PTSD symptoms, that had worsened, in part precipitated by the death of his sister and the suicide of his friend over the past year. Since these events, the Veteran related that he found himself feeling increasingly more irritable and noted that he had actually been asked to leave his local VFW club due to an argument he had with another member. He reported worsening anhedonia and social withdrawal and that he was easily angered. He related that although he used to enjoy playing darts, he did not enjoy this activity anymore. He continued to avoid crowds and remained hypervigilant. He described increased disrupted sleep and nightmares. He denied any crying spells, but found himself feeling disgusted at times. He reported increased rumination and acknowledged problems with anxiety, noting that January had been a difficult month for him. He reported fair concentration. Mental status examination revealed that the Veteran was neatly and casually dressed. He maintained variable eye contact. His speech was goal-directed with direct questions, but often over-detailed. He denied any suicidal or homicidal ideation, but admitted that he had passive suicidal ideation most recently in November 2008 following the suicide of his friend. He denied any hallucinations of the five senses and denied any concerns for his safety. He denied delusions. He admitted to tending to like things clean and orderly, but denied any obsessions, compulsions of phobias. He indicated that he found himself increasingly more ruminative. He acknowledged problems with anxiety, but denied any frank panic attacks. His fund of knowledge was good. Judgment and insight were fair. He was alert and oriented times 3. PTSD, major depressive disorder (recurrent) and alcohol dependence were assessed. A GAF score of 43 was assigned. In February 2009, the Veteran related his reasons for disagreeing with the continued assignment of a 50 percent evaluation for PTSD. He noted that he was still having panic attacks weekly and had not worked since September 2008. He noted that he had divorced and never re-married. He noted also that he had been banned from his VFW for getting into a fight with someone there, and that he did not like crowds. An August 2009 VA treatment record documents that medication was helping with the Veteran's sleep disturbance. At this time, the Veteran related that he was not as moody and irritable. His girlfriend was noted as very supportive and would purchase groceries and clothes for him. He related that there were a few days when he did not consume any beer, but that if he had the readiness, he may finish a "pack a day." He did not go to bars and avoided bars where there was a crowd of people. He enjoyed taking his dogs for a ride and spent some time in the garden. He related feeling a lot better over the past 2 weeks. An October 2009 VA treatment record relates to a cognitive therapy session. At this time, the Veteran related that nothing went smoothly for him on the job or at home. He related that he was not able to take things in stride any more. He stated that his prostate cancer may have been arrested by radiation, but that he continued to be unable to work or muster sufficient energy to seek employment. Subsequent VA psychology records document similar impressions and reports. A January 2010 VA note documents that the Veteran continued to struggle with strong efforts to avoid activities and social situations. In May 2010, the Veteran was afforded another VA examination. The examination report noted that the Veteran continued to receive and participate in psychiatric counseling and that although it was supportive, no real change in the Veteran's condition had occurred. He was taking medication for depression and anxiety. He remained single, but continued to have a girlfriend. He related that the relationship was rocky due to his aggressive and belligerent behavior, although he cared deeply about her and wanted the relationship to work. He related having few friends and that he preferred to isolate himself from others. There was no history of suicide attempts. He had no major problems of violence/assaultiveness in the past year, although he had a long history of being abusive toward others. He continued to use alcohol, but had decreased his consumption. Mental status examination revealed that he was clean and casually dressed. He seemed tired and worn out. His speech was slow and clear. He was cooperative and guarded, and willing to share information even when painful to him. His affect was blunted. He was anxious and depressed. Attention was intact and he was oriented times 3. His thought process was unremarkable. His thought content was depressed and discouraged. He had no delusions and judgment was intact. Intelligence was average and he had insight that he had a problem. He continued to complain of sleep impairment. He complained of being tired, having poor concentration and low energy. He had no hallucinations. He had no inappropriate behavior. He interpreted proverbs appropriately. He had no obsessive/ritualistic behavior. He had panic attacks. He experienced periodic episodes of anxiety and panic, as well as episodes of anger. There was no presence of suicidal or homicidal thoughts. His impulse control was fair. He had episodes of violence. He was able to maintain minimum personal hygiene and there were no problems with activities of daily living. His memory (remote, recent and immediate) was normal. He was found competent and was then self-employed, although it was noted that he was unable to work due to prostate cancer and its treatment. His PTSD signs and symptoms were noted as restricting his work due to poor concentration, poor emotional control and poor social interaction. PTSD with depression was assessed. A GAF score of 50 was assigned and the examiner remarked that there was reduced reliability and productivity due to PTSD. Following this VA examination, there are VA records pertaining to psychiatric treatment dated through April 2011. These records document similar impressions and that he continued to avoid activities and social situations. They also document continued assessments of severe PTSD, as well as significant grief over the death of his mother in November 2010. Resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD warrants an increased rating of 70 percent. Specifically, it has resulted in occupational and social impairment, with deficiencies in most areas, due to suicidal ideation, near-continuous panic and depression, unprovoked irritability, difficulty in adapting to stressful circumstances, particularly in a work-like setting, and inability to establish and maintain effective relationships. It is particularly salient to the Board that the Veteran's GAF scores have range from 55 to 65, but that these scores predominate lower than 60, with a low GAF score of 43. This indicates predominately moderate to serious symptoms associated with PTSD. Richard, supra. Accordingly, the Board finds that the Veteran's symptoms more closely approximate a 70 percent rating for PTSD, throughout the course of the present claim and appeal. Hart, supra. However, although an increased rating of 70 percent is warranted, the evidence of record does not reflect symptomatology of PTSD that would meet the criteria for an even higher rating of 100 percent. Although the evidence demonstrates a significant degree of occupational and social impairment due to PTSD, it does not show total occupational and total 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, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Indeed, the Veteran has been able to maintain some interpersonal relationships and was gainfully employed up until he was diagnosed as having prostate cancer, which has been considered in the award of a TDIU. In short, there is simply no evidence to support an increased rating of 100 percent. Even considering that the Veteran's disability has resulted in significant occupational impairment, his PTSD has not been shown to result in total social impairment. As such, a rating in excess of 70 percent under Diagnostic Code 9411 is not warranted for any time during the course of the present claim and appeal. Hart, supra. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to a rating in excess of 70 percent, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Extraschedular Consideration According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. It is appropriate to consider extraschedular referral on a "disability-by-disability" basis. Johnson v. Shinseki, ___ Vet. App. ___, No. 10-1785, 2013 WL 1224810 (Vet. App. March 27, 2013). With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected condition is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The criteria particularly contemplate his specific symptoms and the conditions social and industrial impairment. The Board further observes that, even if the available schedular evaluation for his disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent, or any, hospitalizations for his PTSD. Additionally, there is not shown to be evidence of marked interference with employment due to this disability not contemplated by his 70 percent rating. Moreover, there is no evidence in the medical records of an exceptional or unusual clinical picture. In short, there is nothing in the record to indicate that the service-connected disability on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. (CONTINUED ON NEXT PAGE) ORDER Entitlement to an initial evaluation of 70 percent, but no greater, for PTSD is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs