Citation Nr: 1323330 Decision Date: 07/22/13 Archive Date: 08/01/13 DOCKET NO. 08-00 112 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to a disability evaluation in excess of 50 percent prior to October 30, 2012 and to a disability evaluation in excess of 70 percent thereafter for service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. G. Alderman, Counsel INTRODUCTION The Veteran served on active duty in the United States Marine Corps from June 1951 to June 1954 and with the United States Air Force from January 1955 to February 1975. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office in Houston, Texas (RO). In that rating decision, the RO continued a 10 percent evaluation for PTSD. In March 2011, the Veteran testified before the undersigned during a hearing at the RO. A copy of the hearing transcript has been associated with the claims folder. In June 2011 and October 2012, the Board remanded this matter, as well as a claim for a total disability rating based on individual unemployability (TDIU), for additional development, to include obtaining outstanding treatment records and scheduling VA examinations. All development has been completed. See Stegall v. West, 11 Vet. App. 268 (1998). In May 2013, the RO via the Appeals Management Center (AMC) granted entitlement to TDIU, effective December 9, 2004, the date of claim. Therefore, the issue of TDIU is no longer before the Board. The RO/AMC also granted a 50 percent evaluation prior to October 20, 2012 and granted a 70 percent evaluation from that date for PTSD. Since the Veteran has not been granted a total rating for the entirety of the appeal period for PTSD, and since the Veteran has not expressed satisfaction with the current evaluations, the issue remains before the Board for consideration. The Board has reviewed the Veteran's physical claims file and file on the "Virtual VA" system to insure a total review of the evidence. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Prior to October 30, 2012, the Veteran's PTSD symptoms were not of the severity to cause 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; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships. 2. Since October 30, 2012, the Veteran's PTSD has not been of the severity to cause total occupational and social impairment. CONCLUSION OF LAW The criteria for a disability evaluation in excess of 50 percent prior to October 30, 2012 and to a disability evaluation in excess of 70 percent thereafter for service-connected PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Duty to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100% "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In this case, the duty to notify was not satisfied prior to the initial unfavorable decision on the claim by the RO. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the RO's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the RO) see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case (SSOC), is sufficient to cure a timing defect). The RO's January 2005 and May 2008 letters to the Veteran satisfied the duty to notify provisions relating to the Veteran's claim. 38 U.S.C.A. § 5103 (a); 38 C.F.R. § 3.159 (b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The letters informed the Veteran of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. The May 2008 letter notified him that he must submit, or request that VA obtain, evidence of the worsening of his disabilities and of the different types of evidence available to substantiate his claim for a higher rating. Moreover, these letters informed him of the requirements to obtain higher ratings and notified him of the need to submit evidence of how such worsening effected his employment. See Vazquez-Flores v. Shinseki, 580 F.3d at 1275-82. Although the May 2008 notice letter was not sent before the initial RO decision in this matter, the Board finds that this error was not prejudicial to the Veteran because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has he been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the RO also readjudicated the case by way of a June 2012 SSOC after the notice was provided. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. The duty to assist the Veteran has been satisfied in this case. The RO has obtained the Veteran's service treatment records and his identified VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Moreover, the Veteran has been afforded multiple VA examinations that are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Specifically, the Veteran had VA examinations in February 2005, April 2007, July 2011, and October 2012. While the February 2005 examiner did not indicate that he reviewed the claims file in conjunction with the examination, the Board notes that the issue at the time of the examination was the current severity of the Veteran's PTSD; therefore, he has not been prejudiced by the examiner's inability to review past treatment records. Moreover, the April 2007, July 2011 and October 2012 examiners did review the claims file and consider the Veteran's statements when determining the current severity of his PTSD. Therefore, the VA examinations are adequate for rating purposes. As such, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Increased Ratings Generally, disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). 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 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). 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 (2012). 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). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where a veteran appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of the veteran's disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, where VA's adjudication of a claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms, which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21 (2012). Therefore, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Veteran's PTSD has been assigned a 50 percent evaluation prior to October 30, 2012 and a 70 percent evaluation from that date under Diagnostic Code 9411. 38 C.F.R. § 4.130. Under Diagnostic Code 9411, a 50 percent evaluation is warranted where there is 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; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. Under Diagnostic Code 9411, a 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; 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. Id. A 100 percent evaluation is warranted where there is 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. Id. The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are 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 when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). The Board observes that the words "slight," "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. VA treatment records dated January to August 2004 show reports of intrusive thoughts, occasional nightmares, hyperarousal, improvement with sleep, moderate hypervigilence, and avoidance behaviors. The Veteran was interacting well with family but he was not dating. The provider observed mildly depressed mood. His judgment and insight were fair. A GAF score of 50 was assigned. A December 2004 PTSD status summary states that the Veteran had chronic major depression with emotional withdrawal and physical isolation. His GAF score was 52. The provider said his GAF score had ranged from 45 to 55 in the past year. December 2004 and January 2005 VA group therapy notes show a GAF score of 48. The Veteran had a VA examination in February 2005. The Veteran said he saw his children and grandchildren regularly and that he cared for the youngest grandchild on Saturdays. He missed his daughter, whom had recently moved to Hawaii, and other than contact with his family, he lived an isolated life. He also harbored resentment towards the military because he met the "love of his life" while stationed in Japan but was prohibited from marrying her. The military shipped him to Korea to increase the distance between him and the woman. He blamed all of his failed relationships on his inability to forget her. When overwhelmed with the sense of her loss, his thought process will become confused rendering him unable to communicate because of his sense of loneliness and estrangement. Otherwise, he thinks clearly and uses language to express his ideas fluently and intelligently. The diagnosis was chronic PTSD. A GAF score of 65 was assigned. The examiner said it is unlikely that the Veteran would ever be employable given his unemployment since November 2002 and the progression of his diabetes mellitus. He said the Veteran's primary PTSD symptom is the loss of the woman and when he misses her most, he experiences dreams, nightmares, and daydreams of the combat and non-combat terrors he witnessed or otherwise survived during service. Since becoming more symptomatic with his diabetes mellitus and since his daughter relocated, his sense of loss was somewhat more acute. VA treatment records dated October through December 2005 show that the Veteran was mourning the loss of his grandson, a murder victim. The provider observed mildly depressed mood and diagnosed PTSD and bereavement. A GAF score of 47 was assigned. In June 2006, he continued to express bereavement over his grandson's death. He was anxious and angry over the upcoming trial of the perpetrator. The diagnosis of PTSD and bereavement was continued. A GAF score of 48 was assigned. An August 2006 VA treatment record shows that the Veteran had mild PTSD due to in-service stressors. His major depression was attributed more to non-combat, non-trauma events during the military than to his war trauma. The provider observed that the Veteran's mood and affect were mildly depressed and anxious. The diagnoses were PTSD, mild, and major depression, chronic, mild with melancholic features. The GAF score was 60. No changes in symptoms or findings were made in September 2006; however, a GAF score of 65 was assigned. In October 2006, the provider observed euthymic mood and assigned a GAF score of 48. From November 2006 through February 2007, the Veteran's mood was described as mildly depressed and/or anxious. PTSD and major depression were diagnosed and a GAF score of 65 was assigned. In March 2007, the provider observed increased depressive symptoms and assigned a GAF score of 60. Another March 2007 treatment record notes that the Veteran had started a new relationship with a woman. He endorsed continued intrusive thoughts and mild avoidance behaviors. His mood was euthymic. The GAF score remained at 60. The same day, the Veteran reported that his girlfriend might be moving in two months. The Veteran said he felt lonely, irritable and sad. The provider assigned a GAF score of 52. The Veteran had a VA examination in April 2007. The Veteran said accounts of war in Iraq would trigger memories from his period of service and make him sad and sometimes mad. He had occasional nightmares about dead bodies and/or military combat. The examiner said the Veteran's social functioning since his last VA exam had been limited. He socialized with his PTSD therapy group and his daughter. He noted that the trial for his grandson's murder was the following month and that he was preparing a victim statement. He feared getting close to his other grandson because of the murder. The examiner said the psychosocial functional status and quality of life since the last examination were unchanged. The examiner observed that life circumstances unrelated to combat trauma exacerbated the Veteran's problems functioning, including his relationship losses and the murder of his grandson. The prognosis was guarded for further improvement. The diagnosis was chronic PTSD with a GAF score of 60 for moderate symptoms. The examiner said the Veteran's functional impairment is greatly influenced by physical problems and that his PTSD symptoms seemed relatively unchanged over the years, dating back to his period of employment, successful retirement, and subsequent employment as a contractor. During his March 2011 Board hearing, the Veteran testified that he spends most of his time sitting at home. He said he leaves his home to get breakfast and check his mail each day but has no extracurricular activities. He said he feels lonely and depressed almost every day. His symptoms included avoidance of crowds, startle response, and nightmares once every four to five months. He said his daughter and her children lived nearby and that he sees them every weekend. He sees his son a couple of times per month. Regarding employment, he said he quit working because his feet and ankles were swelling, he had problems hearing, and he had problems looking at a computer or reading for extended periods. He also said he would drift off while working. Between September 2007 and October 2008, the Veteran endorsed feelings of guilt and sadness. Treatment records show he discussed the trial for his grandson's murderer, and in May 2008, he said he felt closure after the murderer was convicted and sentenced. Records also show that he and his son had started to repair their relationship. During this period, the providers noted intrusive thoughts, mild avoidance behaviors, and mildly depressed mood. GAF scores ranged between 52 and 58. By November 2008, he was dating again. A GAF score of 59 was assigned. May 2009 treatment records show that he became engaged and that he started exercising. He still endorsed intrusive thoughts and avoidance behaviors. His mood was euthymic. A GAF score of 57 was assigned. During a follow-up appointment about a week later, the provider observed that the Veteran's mood and affect were nearly euthymic and that he was at a good baseline that had been sustained for a number of months. A GAF score of 62 was assigned. In July 2009, the Veteran's fiancée and her son moved in with him. The GAF scores from July 2009 until April 2011 ranged from 58 to 62. In April 2011, the provider said the Veteran was at baseline but reported some depressive feelings. The provider also said the Veteran showed mild symptoms of PTSD on a regular basis but generally functioned pretty well. He noted that the Veteran had physical problems that limited his activity. A GAF score of 62 was assigned. A June 2011 treatment record shows that the Veteran was not happy with his girlfriend or her son. He said they did not talk much and that he was going to ask her to leave. He reported depressive feelings. His mood and affect were depressed. The diagnoses included mild PTSD and chronic, major depression. A GAF score of 62 was assigned. In July 2011, his relationship with his girlfriend had improved. No change in symptoms or diagnosis was noted. Available treatment records show that the Veteran's symptoms and GAF scores remained stable through August 2012. The Veteran had a VA examination in July 2011. He said he has been living with his girlfriend of two years and that the relationship is strained at times due to his irritability and emotional detachment. He continued to have good relationships with his adult children. He said he does not socialize outside his family and has lost interest in activities he previously found pleasurable. He said the loss of interest in activities is due to grief associated with the death of his grandson; however, the examiner said it is also a PTSD symptom. The Veteran stopped working in 2002 due to physical ailments. The examiner found that the Veteran's PTSD caused depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbance of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The diagnosis was PTSD with a GAF score of 58. The examiner indicated that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity. In the opinion, the examiner said it is less likely as not that the PTSD renders the Veteran unable to secure or follow substantially gainful employment. The examiner noted the Veteran's lengthy and stable work history and that he retired due to physical as opposed to mental ailments. The Veteran denied PTSD-related effects on occupational functioning other than occasional poor interactions with others. The examiner said that while the Veteran's symptoms may have worsened to some degree since retirement, his PTSD symptoms do not appear of the severity to preclude gainful employment. The examiner opined that the symptoms observed during the examination are of the moderate range which would likely be associated with reduced reliability and productivity in an occupational setting. The Veteran may become emotionally overwhelmed and unfocused at times, but not likely to the degree where he would be unable to work. The examiner also noted that while recent reports show mild symptoms, the current evaluation suggests that the Veteran's symptoms have worsened over time. In an August 2012 statement, the Veteran said he did not feel safe in shopping malls, theaters, or large groups of people due to anxiety, anxiousness, anger, fear, and depression. His inability to establish and maintain effective work, social, family, and marital relationships have cause him to withdraw from others. He noted his previous five marriages and said his relationships did not last because he was not able to cope with irritable, stressful, and unfulfilling situations such as financial and sexual matters. He noted that he was single and said he rejected the love and support of his family because of his feelings of sadness and not being understood by his family. An August 2012 statement from the Veteran's private internal medicine provider, V.G.G., MD, states that the Veteran's PTSD is moderate to severe in intensity and precludes him from performing normal activities of daily living and normal social activities such as going to the mall or theaters, or be around large crowds. Notably, Dr. V.G.G. has not treated the Veteran's PTSD, did not indicate that he reviewed the Veteran's claims file, and did not indicate the rationale for his finding of moderate to severe PTSD. Therefore, his statement has no probative value. The Veteran had a VA examination in October 2012. After the previous VA examination, the Veteran ended his relationship with his girlfriend. He continues to have good relationships with his adult children and grandchildren. He does not socialize outside of his family but occasionally contacts old friends from the military. Symptoms include poor sleep, occasional nightmares, discomfort in crowds and around strangers, irritability, and social isolation. He still avoids movie theaters and feels more like he is old and in everyone's way. His avoidance of crowds is worsening because his physical limitations make him feel unable to defend himself. The examiner noted depression, anxiety, chronic sleep impairment, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. The diagnosis was chronic PTSD with a GAF score of 60. The examiner said the Veteran's PTSD is moderate based on the examination and a review of the records. The examiner pointed out a statement from the Veteran's private internal medicine provider which indicates that his PTSD is moderate to severe. However, the examiner noted that records from the Veteran's primary psychologist, dated as late as July 2012, describe PTSD as mild and that the internal medicine provider did not give supporting evidence to support the finding of moderate to severe PTSD. The examiner found that the Veteran's PTSD causes reduced reliability and productivity in an occupational setting and that he may become emotionally overwhelmed and unfocused at times, but not likely to the degree where he would be unable to work. The examiner said PTSD does not interfere with the Veteran's activities of daily living. After reviewing the evidence of record, the Board finds no evidence that would warrant a rating in excess of 50 percent for the Veteran's service-connected PTSD at any time prior to October 20, 2012. 38 U.S.C.A. 5110 (West 2002); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no distinct periods of time prior to October 20, 2012 during which the Veteran's PTSD has varied to such an extent that a rating greater or less than 50 percent would be warranted. Specifically, although a few GAF scores assigned were in the upper 40s, indicating serious symptoms or serious social or occupational impairment, the majority of the GAF scores during this period were in the 50s and 60s, indicating mild to moderate symptoms. In addition to considering GAF scores, the Board must look at the clinical findings. During this period, the clinical findings do not show suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; 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; or the inability to establish and maintain effective relationships. Thus, when considering the overall disability picture, including GAF scores and clinical findings, the Board finds that an evaluation in excess of 50 percent is not warranted prior to October 20, 2012. As for entitlement to an evaluation in excess of 70 percent from October 20, 2012, there is no evidence of record suggesting that a higher evaluation for this period is warranted. 38 U.S.C.A. 5110; see also Hart, 21 Vet. App. 505. The Veteran does not endorse symptoms such 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; memory loss for names of close relatives, own occupation, or own name. Per the October 2012 VA examiner, PTSD causes only reduced reliability and productivity in an occupational setting. The examiner assigned a GAF score of 60, which suggests moderate symptoms. The examiner specifically found that the Veteran's PTSD would not render him unable to work; thus, his condition does not cause total occupational impairment. Further, the Veteran has good relationships with his adult children and grandchild, and on rare occasions, contacts his military friends; therefore, his PTSD does not cause total social impairment. Consequently, the overall disability picture does not support a rating in excess of 70 percent from October 20, 2012. In reaching the decision that increased ratings are not warranted for any period during the pendency of the claim, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the assignment of increased evaluations, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has also considered whether referral for extraschedular evaluations is warranted. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). 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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between 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. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned evaluations inadequate. The Veteran's service-connected PTSD has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his PTSD. Id. Evaluations in excess of those currently assigned are provided under Diagnostic Code 9411; however, as discussed above, the severity of the Veteran's PTSD does not rise to the level of the next higher evaluations. The Board has considered the medical and lay evidence, but finds that the schedular criteria adequately address the severity of the Veteran's PTSD during the pendency of his claim. Consequently, the Board concludes that the schedular evaluations are adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). ORDER Entitlement to a disability evaluation in excess of 50 percent prior to October 30, 2012 and to a disability evaluation in excess of 70 percent thereafter for PTSD is denied. ____________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs