Citation Nr: 1323227 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 07-28 285 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from August 1988 to January 1992 and from February 2002 to February 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, in which the RO, in pertinent part, granted service connection and assigned an initial 10 percent rating for PTSD, effective April 13, 2006. In a July 2007 rating decision, the RO granted a 30 percent initial rating for PTSD, effective April 13, 2006. Despite the grant of this higher initial rating, the Veteran has not been awarded the highest possible evaluation, and his claim remains in appellate status. A.B. v. Brown, 6 Vet. App. 35 (1993). During the pendency of the appeal, the case was transferred to the jurisdiction of the RO in Houston, Texas, which certified the case for appellate review. In August 2012, the Board remanded the claim for a higher initial rating for PTSD to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. After completing the additional development, the AMC continued to deny the claim (as reflected in a June 2013 supplemental statement of the case (SSOC)), and returned this matter to the Board. The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence that has been considered by the AMC in the June 2013 SSOC. Therefore, the Board's consideration of this evidence will not result in prejudice to the Veteran. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. Since April 13, 2006 (the effective date of the grant of service connection), the Veteran's PTSD has been manifested by depressed mood, sleep impairment (including nightmares), intrusive thoughts, flashbacks, startle response, anger, irritability, hypervigilance, anxiety, and reports of memory impairment which is no worse than mild; these symptoms are indicative of no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria for an initial rating in excess of 30 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (Court) have been fulfilled. The Veteran's claim for service connection for PTSD was received in April 2006. Thereafter, he was notified of the general provisions of the VCAA by the RO in correspondence dated in May 2006. This letter notified the Veteran of VA's responsibilities in obtaining information to assist him in completing his claim, identified the Veteran's duties in obtaining information and evidence to substantiate his claim, and provided other pertinent information regarding the VCAA. Thereafter, the claim was reviewed and the RO issued the October 2006 rating decision granting service connection for PTSD. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). The Court, in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), held that the VCAA notice requirements apply to all elements of a claim. Notice as to these matters was provided in the May 2006 VCAA letter. The Board notes that the claim for a higher initial rating for the Veteran's service-connected PTSD is a downstream issue, which was initiated by a notice of disagreement. The Court has held that, as in this case, once a notice of disagreement from a decision establishing service connection and assigning the rating and effective date has been filed the notice requirements of 38 U.S.C.A. §§ 5104 and 7105 control as to the further communications with the appellant, including as to what "evidence [is] necessary to establish a more favorable decision with respect to downstream elements...." Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Hence, there is no duty to provide additional VCAA notice in this case. Review of the claims file and Virtual VA e-folder shows that VA has conducted reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claim during the course of this appeal. His VA treatment records, including Vet Center treatment records, have been obtained and associated with his claims file and Virtual VA e-folder. The Veteran was also provided with a VA examination to evaluate his PTSD in June 2006. In August 2012, the Board remanded the claim to obtain the Veteran's VA treatment records from June 2007 to May 2008 and since May 2011, to obtain the Veteran's Vet Center treatment records, and to afford the Veteran a VA examination to evaluate his PTSD. The VA and Vet Center treatment records identified in the August 2012 remand have been obtained. In August 2012, the AMC sent the Veteran a letter advising him that the San Antonio VA medical facility had been asked to schedule him for an examination in connection with his claim, and that facility would notify him of the date, place, and time of the examination. The August 2012 letter informed the Veteran that, if he could not keep the appointment, or wanted to be rescheduled, he should notify the medical facility on the appointment notice as soon as possible. The AMC further informed the Veteran that when a claimant, without good cause, fails to report for an examination or re-examination, the claim shall be rated based on the evidence of record, or even denied. Later that month, the San Antonio VA Outpatient Clinic (OPC) sent the Veteran a letter advising him that he had been scheduled for a VA examination in September 2012. This letter was not returned by the U.S. Postal Service as undeliverable; however, the Veteran failed to report for the September 2012 VA examination. He has failed to provide good cause for his failure to report. Pursuant to 38 C.F.R. § 3.655, when a Veteran fails to report for a VA examination or re-examination that is scheduled in conjunction with an original claim, and he fails to provide good cause for this failure to report, the claim shall be rated based on the evidence of record, and as such, could result in denial of the claim. See 38 C.F.R. § 3.655(b). Moreover, the Board notes that examples of "good cause" for failure to report for a VA examination include illness or hospitalization of the claimant and death of an immediate family member. See 38 C.F.R. § 3.655(a). The Veteran failed to report for his September 2012 VA examination, and has failed to provide any explanation for his failure to report. As such, his claim for a higher initial rating for PTSD will be rated on the evidence currently of record. See 38 C.F.R. § 3.655(b). In making this determination, the Board highlights that the duty to assist is not a one-way street; a claimant cannot stand idle when the duty to assist is invoked by failing to provide important information or otherwise failing to cooperate. Wood v. Derwinski, 1 Vet. App. 190 (1991) (aff'd on reconsideration, 1 Vet. App. 460 (1991); Olson v. Principi, 3 Vet. App. 480, 483 (1992). In light of the foregoing, the Board finds that there was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Board has considered that an April 2011 VA treatment record indicates that the Veteran asked his physician to fill out paperwork for Social Security disability. Ordinarily, when VA is put on notice of the existence of Social Security Administration (SSA) records, it must try and obtain them before proceeding with the appeal. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992); see also Lind v. Principi, 3 Vet. App. 493, 494 (1992). However, because the Veteran failed to report for a necessary VA examination without good cause, his claim must be decided based on the evidence of record, and VA has no further duty to attempt to obtain any additional records (including SSA disability records). 38 C.F.R. § 3.655(b). In any event, in Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009), the United States Court of Appeals for the Federal Circuit clarified that VA's duty to assist was limited to obtaining relevant SSA records. The Veteran himself reported in his April 2010 VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, that he was unable to secure or follow a substantially gainful occupation as a result of his radiculopathy, lumbar degenerative disc disease, and degenerative arthritis. He did not mention his PTSD. Accordingly, any outstanding SSA records would not be pertinent to the claim on appeal. Given the foregoing, the duty to assist has been satisfied, and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating his claim. Factual Background and Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where, as here, the question for consideration is entitlement to a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In the October 2006 rating decision, the RO granted service connection and assigned an initial 10 percent rating for PTSD, effective April 13, 2006, pursuant to Diagnostic Code 9411. 38 C.F.R. § 4.130, Diagnostic Code 9411. In the July 2007 rating decision, the RO granted a 30 percent initial rating pursuant to this Diagnostic Code. The criteria for rating psychiatric disabilities other than eating disorders are set forth in a general rating formula. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. Under the formula, a 30 percent rating is assigned when there is 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 assigned for 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 assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; 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 closes relatives, own occupation, or own name. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not 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). Considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that an initial rating in excess of 30 percent for service-connected PTSD is not warranted. Records of VA treatment dated from August 2006 to March 2013 reflect mental health treatment with diagnoses of and treatment for depression and PTSD. These records also reflect treatment for symptoms related to in-service traumatic brain injury. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). There is no indication that it is possible to distinguish the symptoms from the Veteran's depression, traumatic brain injury, and PTSD as described in the VA treatment records. Accordingly, the Board has considered all of the pertinent symptoms described in the treatment records in evaluating the Veteran's service-connected PTSD. The Veteran was afforded a VA examination to evaluate his PTSD in June 2006. He gave a history of trouble sleeping for two years, with frequent awakening. He described intrusive thoughts, flashbacks, startle response, and anger. He stated that, as a result of these symptoms he avoided people, was isolated, and experienced anger. He denied receiving any treatment for his psychiatric condition. He reported that, since leaving service, he had worked as a freight handler for eight months. He described a good relationship with his supervisor and a fair relationship with his co-workers. He reported problems with angry outbursts at work. The Veteran stated that he was divorced but had a significant other and described his relationship as "adequate." He added that he had good relationships with his children. He stated that he had a lack of friends and no recreational outlets. He added that he was isolated, worked at night to avoid people, and shopped alone at night. The Veteran described symptoms including markedly diminished interest or participation in significant activities, emotional distancing, restricted range of affect described as emotional numbing, persistent difficulty falling or staying asleep, irritability or outbursts of anger which were problematic at home and at work, difficulty concentrating described as lack of focus, persistent exaggerated startle response, and persistent hypervigilance. On mental status examination, the Veteran was oriented with appropriate appearance, hygiene, and behavior. Affect and mood were abnormal in that the Veteran had depressed mood as often as three times a month, with each episode lasting for four days. The Veteran reported anxiety, depression, and anger, with anxiety being the most problematic. Communication, speech, and concentration were within normal limits. Panic attacks and obsessional rituals were absent. There were no delusions or hallucinations by history or observed on examination. Thought processes were appropriate, judgment was not impaired, and abstract thinking and memory were normal. Suicidal and homicidal ideation was absent. The Veteran had no difficulty understanding commands. The Axis I diagnosis was PTSD and the examiner assigned a GAF score of 75. The examiner commented that the Veteran worked full-time but had to struggle and worked at night to avoid people. He added that the Veteran did not have difficulty performing his activities of daily living as a result of his mental condition. The examiner described the Veteran's current psychiatric impairment as mild, with transient symptoms which caused occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. VA treatment records dated from December 2006 to May 2011 include a positive depression screen in December 2006. The Veteran underwent a PTSD evaluation in January 2007. He reported that he had one sister with whom he had no contact, lived alone, and had poor social contact. On mental status examination, the Veteran was well-groomed, alert, and oriented. Speech was normal rate and tone. Mood and affect were depressed. Thoughts were organized, coherent, and goal-directed and insight was fair. He reported a history of homicidal ideation, but denied any suicidal ideation, hallucinations, or delusions. The Axis I diagnosis was PTSD and the social worker assigned a GAF score of 55. The social worker commented that the Veteran complained of sleep disturbance, anxiety, depression, and irritability. She observed that he was accompanied to the evaluation by a friend, although he reported minimal social support. The Veteran underwent psychological testing in March 2007. The initial results were consistent with a diagnosis of PTSD and significant functional impairment and/or subjective distress. During PTSD group therapy in March and April 2007, mental status examination was within normal limits and there was no evidence of suicidal ideation, homicidal ideation, or auditory or visual hallucinations. In May 2007, the Veteran denied intrusive memories over the past week, although he experienced nightmares. He reported hyperarousal and avoidance symptoms, but there was no evidence of suicidal ideation, homicidal ideation, or auditory or visual hallucinations. In a May 2007 traumatic brain injury screening, the Veteran reported that he was experiencing memory problems, irritability, and sleep problems. Another traumatic brain injury screening, from June 2007, documents the Veteran's reports of poor concentration, forgetfulness, difficulty making decisions, slowed thinking, difficulty getting organized, an inability to finish things, fatigue, loss of energy, getting tired easily, difficulty falling or staying asleep, feeling anxious or tense, irritability, being easily annoyed, poor frustration tolerance, and feeling easily overwhelmed. During individual and group therapy in June 2007, mental status examination was within normal limits and there was no evidence of suicidal ideation, homicidal ideation, or auditory or visual hallucinations. A depression screen from later that month was negative. In October 2007, the Veteran reported to his physician that he was still irritable and was sometimes angry for no apparent reason. He stated that his PTSD was affecting him at work and commented that he felt he needed medication. In January 2008, the Veteran underwent individual psychotherapy for PTSD. He reported a significant improvement in mood over the past week, and stated that he had been actively taking steps to reduce his stress/anger, including applying anger management and problem solving skills to problematic co-workers at his job. He reported a vast improvement in his ability to cope with relationship stressors. The psychologist commented that the Veteran came across as calm, friendly, and engageable, and there was no evidence of organicity, mania, or psychosis. He described sleep problems, but denied suicidal ideation, homicidal ideation, and auditory or visual hallucinations. The assessment was depression and mild PTSD. The Veteran was seen for treatment related to in-service traumatic brain injury in May 2008, at which time he described concentration and forgetfulness problems. On examination, he had immediate recall of five out of five words and delayed recall of three out of five words. The assessment included PTSD; however, the Veteran indicated to his psychologist that he was not interested in further PTSD treatment as he was feeling stable. He reported that he was still working at his same job. The psychologist commented that mental status examination was within normal limits and there was no evidence of suicidal ideation, homicidal ideation, or auditory or visual hallucinations. The assessment was PTSD, mild. A June 2008 speech pathology consultation report reflects that the Veteran was evaluated for cognitive deficits related to his history of traumatic brain injury in-service. He reported problems with concentration, attention, and memory. Specifically, he stated that he had difficulty recalling information such as his children's birthdays. The speech pathologist commented that the Veteran's responses on the neurobehavioral symptom inventory were notable for moderate difficulties with decision making and slowed thinking/organization, and severe difficulties with concentration and memory. The Veteran reported that he felt he was doing OK at his full-time job in inventory management because his job told him what to do. He added that he was taking three online classes and had received A's in two classes the previous semester. The speech pathologist commented that the Veterans' current cognitive assessment revealed intact orientation and visual reasoning, with likely intact sustained attention and processing speed. Recent memory was mildly impaired on testing, which, he stated, could be influenced by the Veteran's traumatic brain injury, PTSD, and poor sleep patterns. In January 2009, the Veteran contacted his psychologist to request follow-up to address recent difficulty managing irritability. The psychologist indicated that the Veteran's speech was of normal rate, rhythm, volume, and intensity. There was no evidence of cognitive impairment, thought disorder, or psychoses, and memory was intact. Thought processes were logical, linear, and goal-directed. Mood was euthymic. Affect was full-range, appropriate, and non-labile. There was no current suicidal ideation or homicidal ideation. Mental status was described as within normal limits. The Veteran was seen for mental health medication management in May 2009, at which time he noted improvement in his mood since the initiation of sertraline. He reported minimal depressive symptoms, including occasional poor sleep and anergia. He reported nightmares twice a week. He denied suicidal ideation, symptoms of mania, and auditory or visual hallucinations. On mental status examination speech was spontaneous with appropriate rate and volume. Mood was euthymic with appropriate range and intensity of affect. Thoughts were clear, logical, and goal-directed. During treatment in April 2011, the Veteran again reported nightmares and stated he was not able to sleep. A May 2011 individual psychotherapy note indicates that the Veteran presented for treatment with his wife. He reported that he had been increasingly irritable. He stated that he was living with his wife (with whom he had recently reunited after 17 years) and her daughter. On mental status examination the Veteran was alert and oriented with normal behavior and gestures and appropriate dress. Speech was normal in rate, rhythm, volume, and intensity. Memory was intact. There was no evidence of cognitive impairment, thought disorder, or psychoses. Thought processes were logical, linear, and goal-directed. Mood was euthymic and affect was full-range, appropriate, and non-labile. There was no suicidal ideation or homicidal ideation. Mental status was described as within normal limits. Records from the San Antonio Vet Center, dated in June 2011, reflect that the Veteran presented for an intake assessment reporting anger issues, irritability, sleep problems, vivid memories, and sporadic nightmares. His wife accompanied him. He stated that his symptoms seemed to be going from moderate to severe. He denied suicidal or homicidal thoughts, depression, speech difficulty, and slowed thinking. On mental status examination, the Veteran had an anxious affect, but speech was appropriate, memory function was normal, and judgment was fair. There was no evidence of a thought disorder. The Veteran did describe sleep disturbance. The Veteran had a VA chiropractic consultation in January 2012 for lumbar discomfort, at which time no abnormalities in regard to orientation to place, time, and person, or in regard to memory were noted. Collectively, the aforementioned evidence reflects that, since the effective date of the grant of service connection, the Veteran's PTSD has been manifested by depressed mood, sleep impairment (including nightmares), intrusive thoughts, flashbacks, startle response, anger, irritability, hypervigilance, anxiety, and reports of memory impairment which is no worse than mild. These symptoms are reflective of occupational and social impairment no greater than what is contemplated in the currently assigned 30 percent disability rating. At no point since the effective date of the grant of service connection has the Veteran's overall PTSD symptomatology met the criteria for a rating in excess of 30 percent. In this regard, the medical evidence does not show the Veteran to have circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impaired judgment; or other symptoms of PTSD that are characteristic of a 50 percent rating. Rather, speech was within normal limits on VA examination in June 2006 and was normal in rate and tone during VA treatment in January 2007. Speech was of normal rate, rhythm, volume, and intensity in January 2009 and was spontaneous with appropriate rate and volume in May 2009. In May 2011, speech was normal in rate, rhythm, volume, and intensity and it was described as appropriate in June 2011. Panic attacks were absent on VA examination in June 2006. Judgment was not impaired at that time and was described as fair during Vet Center treatment in June 2011. The Board has considered the Veteran's reports of memory impairment, but observes that memory was normal on VA examination in June 2006. The Veteran described memory problems in his May 2007 traumatic brain injury screening and during his June 2008 speech pathology consultation. The speech pathologist commented that the Veteran's responses on the neurobehavioral symptom inventory were notable for severe difficulties with memory; however, recent memory was only mildly impaired on testing. Memory was intact during VA treatment in January 2009 and May 2011 and was normal in June 2011. No abnormalities in regard to memory were noted in January 2012. Mild memory loss is contemplated in the 30 percent rating currently assigned and, in light of the above findings on examination, the Veteran's reported memory impairment is no worse than mild. The evidence does not reflect impairment of short- and long-term memory as contemplated in the criteria for a 50 percent rating. The Board has considered the Veteran's reports of impairment of concentration, as made during the June 2006 VA examination. However, concentration was within normal limits on VA examination at that time. The Veteran also described problems with concentration during treatment related to in-service traumatic brain injury in May 2008; however, he also indicated that he did not want further PTSD treatment at that time as he was feeling stable. The speech pathologist who evaluated the Veteran in June 2008 in conjunction with his traumatic brain injury commented that his responses on the neurobehavioral symptom inventory were notable for severe difficulties with concentration; however, cognitive assessment at that time revealed likely sustained attention. The Board has also contemplated the Veteran's reports of slowed thinking, as indicated in the Veteran's June 2007 traumatic brain injury screening. However, thought processes were appropriate and abstract thinking was normal during the June 2006 VA examination. Thoughts were organized, coherent, and goal-directed during treatment in January 2007. The speech pathologist who evaluated the Veteran in June 2008 in conjunction with his traumatic brain injury commented that his responses on the neurobehavioral symptom inventory were notable for moderate difficulties with slowed thinking/organization; however, cognitive assessment at that time revealed likely intact processing speed. There was no evidence of cognitive impairment or thought disorder and thought processes were logical, linear, and goal-directed in January 2009. Thoughts were logical and goal-directed on examination in May 2009 and May 2011. There was no evidence of a thought disorder during Vet Center treatment in June 2011. Thus, despite his reports of slowed thinking and impairment of concentration, the Veteran's PTSD has not been manifested by impaired abstract thinking consistent with a 50 percent rating. Further, although the Veteran gave a history of homicidal ideation in January 2007, there was no homicidal ideation on VA examination in June 2006, nor was there homicidal ideation during VA treatment in March, April, May, and June 2007, January, May 2008, January 2009, and May 2011. The Board further notes that the Veteran described restricted range of affect during the June 2006 VA examination and, on examination, affect and mood were noted to be abnormal in that the Veteran had depressed mood as often as three times a month, with each episode lasting for four days. Mood and affect were depressed in January 2007. In January 2008, the Veteran reported a significant improvement in mood over the past week. Mood was euthymic and affect was full-range, appropriate, and non-labile in January 2009. In May 2009, the Veteran noted improvement in his mood since the initiation of sertraline and described only minimal depressive symptoms. Mood was euthymic with appropriate range and intensity of affect in May 2009 and May 2011. Affect was described as anxious at the Vet Center in June 2011. The evidence indicates that the Veteran has exhibited disturbances of motivation and mood at least at some times since April 13, 2006. However, as discussed above, the evidence of record indicates that the Veteran's PTSD has not been manifested by several of the symptoms contemplated in the criteria for a 50 percent rating. Notably, depressed mood and anxiety are contemplated in the 30 percent rating currently assigned. Significantly, mental status examination was noted to be within normal limits in March, April, and June 2007, May 2008, January 2009, and May 2011. Importantly, the June 2006 VA examiner described the Veteran's current psychiatric impairment as mild, with transient symptoms which caused occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. Although the results of psychological testing from March 2007 were consistent with a diagnosis of PTSD and significant functional impairment and/or subjective distress, as stated above, mental status examination was within normal limits on several dates subsequent to that testing and the assessment in January and May 2008 was mild PTSD. The Veteran himself reported in May 2008 that he was feeling stable and did not want further PTSD treatment. The Board has considered that the Veteran stated during the June 2006 VA examination that he was isolated, avoided people, and had a lack of friends. However, he described his relationship with his significant other as adequate and reported that he had good relationships with his children. He commented in January 2007 that he had poor social contact; however, he was accompanied to his evaluation at that time by a friend. In January 2008, the Veteran reported a vast improvement in his ability to cope with relationship stressors. A May 2011 treatment record indicates that the Veteran had reunited with his wife and was living with her and her daughter. The Veteran presented for treatment with his wife at that time, and for treatment at the Vet Center in June 2011. Thus, while the Veteran may experience social impairment as a result of his service-connected PTSD, such is contemplated in the 30 percent rating assigned, and the evidence does not demonstrate difficulty in establishing and maintaining effective work and social relationships as contemplated in the criteria for a 50 percent rating. In determining that the Veteran's PTSD has not been manifested by occupational impairment as contemplated in the criteria for a 50 percent rating, the Board has considered the Veteran's comments, made to the June 2006 VA examiner, that he worked at night to avoid people. Nevertheless, he described a good relationship with his supervisor and a fair relationship with his co-workers. As stated above, the VA examiner commented that the Veteran's psychiatric impairment resulted in occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. Although the Veteran reported to his VA physician in October 2007 that his PTSD was affecting him at work, he stated in January 2008 that he was applying anger management and problem solving skills to problematic co-workers at his job. In June 2008, the Veteran reported that he felt he was doing OK at his full-time job. The Veteran also completed coursework during the pendency of the appeal, as the June 2008 speech pathology consultation indicates that he was taking three online classes and had received A's in two classes the previous semester. Although the record indicates that the Veteran later dropped out of his college courses, a February 2010 lay statement submitted in support of claims for increased ratings for service-connected cervical and lumbar spine disabilities indicates that the Veteran had dropped out of his college courses due to pain affecting his concentration and preventing him from class participation. Significantly, the record indicates that the Veteran remained employed until September 2009 and the Veteran himself reported in his April 2010 VA Form 21-8940 that he was unable to secure or follow a substantially gainful occupation as a result of his radiculopathy, lumbar degenerative disc disease, and degenerative arthritis (as opposed to his PTSD). In light of the evidence of record, the Board finds that, since the effective date of the grant of service connection, occupational and social impairment, as contemplated in the criteria for the next higher, 50 percent, rating are not met. It follows that the criteria for an even higher rating likewise are not met. In making this determination, the Board acknowledges that the Veteran has reported irritability and anger, including describing problems with angry outbursts at work during the June 2006 VA examination. However, the evidence simply does not reflect impaired impulse control, such as unprovoked irritability with periods of violence, as described in the criteria for a higher, 70 percent rating. The Board must consider the Veteran's entire symptomatology when determining the appropriate rating. The Board finds that the pertinent evidence of record reflects that the Veteran's overall disability picture most closely approximates that contemplated by a 30 percent evaluation. The Board further finds that neither of the GAF scores assigned during the period in question, 75 in June 2006 and 55 in January 2007, provides a basis for assigning an initial rating in excess of 30 percent for PTSD. According to DSM-IV, a GAF score ranging from 71 to 80 is assigned for transient symptoms and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). A GAF score from 51 to 60 is indicative of 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). In this case, however, as discussed above, there is no evidence of flat affect, circumstantial speech, or panic attacks. Further, as previously noted, a GAF score is not 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). As discussed above, the evidence reflects that the Veteran's overall disability picture most closely approximates that contemplated by the 30 percent rating currently assigned. Under these circumstances, the Board finds that the record presents no basis for assignment of an initial rating in excess of 30 percent for the Veteran's service-connected PTSD, under the applicable rating criteria. As a final point, the Board notes that the assertions of the Veteran had his representative have been considered and the Board has fully considered the Veteran's descriptions of his symptomatology as documented in his treatment records; however, as indicated above, the evidence of record indicates that, since the effective date of the grant of service connection, the Veteran's PTSD has been manifested by symptoms consistent with the assigned 30 percent rating. Under the circumstances of this case, the Board finds that, since the effective date of the grant of service connection, the Veteran's PTSD has not met the criteria for a higher rating. See 38 C.F.R. § 4.7. The above determinations are based on application of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at the Veteran's PTSD has not been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321. The determination of whether a veteran is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. In this regard, the Board must compare the level of severity and symptomatology of the veteran's service-connected disability with the established criteria found in the rating schedule for that disability. See id. If the rating criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are found to be inadequate to evaluate the disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, then the third step requires the case to be referred to the Under Secretary for Benefits or the Director of Compensation and Pension Services to determine whether the disability requires the assignment of an extraschedular rating. Id. The Board finds that referral for extraschedular consideration is not warranted in this case. The Veteran's reported symptoms are contemplated by the rating criteria, as discussed above. There are no symptoms left uncompensated or unaccounted for by the assignment of a schedular rating as both occupational and social impairment are addressed by the criteria found under the General Rating Formula for Mental Disorders. The evidence does not indicate that the Veteran's PTSD presents "such an exceptional or unusual disability picture... as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Because the Board finds that the symptoms and functional limitations caused by the Veteran's PTSD are contemplated by the rating criteria, there is no need to consider whether it causes marked interference with employment. Thun, 22 Vet. App. at 115. However, as discussed above, the Veteran himself reported that he stopped working as a result of disorders other than his PTSD (specifically, radiculopathy, lumbar degenerative disc disease, and degenerative arthritis). Consequently, the Board finds that the available schedular evaluations are adequate to rate this disability, and therefore referral for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321(b); Thun, 22 Vet. App. at 115. For all the foregoing reasons, the claim for a higher initial rating for PTSD must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the assignment of a higher initial rating, that doctrine is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial rating in excess of 30 percent for PTSD is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs