Citation Nr: 1323749 Decision Date: 07/25/13 Archive Date: 08/06/13 DOCKET NO. 07-38 198 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to rating in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period prior to December 7, 2009. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD C. Fields, Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1973. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In a September 2006 rating decision, the RO increased the rating from 10 percent to 30 percent. The Veteran disputed the 30 percent rating. In a January 2010 rating decision, the RO granted a rating of 70 percent for PTSD, effective December 7, 2009. The matter continued on appeal. This case has been before the Board on several prior occasions. The Veteran and his wife testified before a Veterans Law Judge (VLJ) sitting at the RO in January 2009. In May 2009, that VLJ remanded the case to the agency of original jurisdiction (AOJ) for additional development. Thereafter, the VLJ who conducted the prior hearing and issued the May 2009 remand retired. As the Veteran requested another Board hearing, the case was again remanded for that purpose in January 2010. In February 2011, the Veteran and his wife testified before the undersigned VLJ at the RO. A transcript of each hearing is of record. In April 2011, the Board issued a decision denying a rating in excess of 30 percent for the period prior to December 7, 2009, and a rating in excess of 70 percent for the period thereafter, for PTSD. The Veteran appealed from this decision to the Court of Appeals for Veterans' Claims (Court). In a September 2012 Memorandum Decision, the Court vacated and remanded the portion of the April 2011 decision that denied a rating in excess of 30 percent for PTSD for the period prior to December 7, 2009. In contrast, the Court determined that the Veteran had abandoned the appeal as to the issue of a rating in excess of 70 percent for the period from December 7, 2009, forward. As such, that portion is not on appeal. The Veteran's paper claims file and Virtual VA paperless claims file have both been reviewed and considered. The Veteran submitted additional evidence in May 2013, and his representative waived review of such evidence by the agency of original jurisdiction (AOJ) in the June 2013 appellate brief. See 38 C.F.R. §§ 20.800, 20.1304(c) (2012). As such, the Board may consider such evidence. FINDINGS OF FACT 1. For the period prior to October 13, 2009, the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity; but not deficiencies in most areas, or total occupational and social impairment. 2. For the period beginning October 13, 2009, the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. CONCLUSIONS OF LAW 1. For the period prior to October 13, 2009, the criteria for a disability rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. For the period beginning October 13, 2009, the criteria for a disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations require VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not in the record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186 (2002). These notice requirements apply to all elements of a claim, including the degree and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). In this case, the Veteran was advised in May 2006, prior to the initial unfavorable rating decision, of the evidence and information necessary to substantiate his claim, the responsibilities of the Veteran and VA in obtaining such evidence, and the evidence and information necessary to establish a disability rating and an effective date, in accordance with Dingess/Hartman. Although no longer strictly required, the Veteran was further advised in May 2008 of the rating criteria and potential daily life evidence. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (vacating Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008), to the extent that it requires more than "generic notice"). The claim was then readjudicated, including in a January 2010 supplemental statement of the case, thereby curing any timing defect. See Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Board notes that the undersigned VLJ did not explain the bases of the prior determination concerning the rating for PTSD, or suggest the submission of evidence that may have been overlooked, during the February 2011 Travel Board hearing. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (discussing the requirements of 38 C.F.R. 3.103(c)(2)). However, the VLJ asked specific questions in an attempt to obtain evidence to establish the severity of the Veteran's current symptoms and substantiate this claim, and the Veteran discussed his symptoms in detail. Moreover, neither the Veteran nor his representative has argued that VA failed to comply with 38 C.F.R. 3.103(c)(2), or identified any prejudice as a result of the Board hearing. Rather, the hearing focused on the elements necessary to substantiate the claim, and the Veteran and his representative demonstrated actual knowledge of such elements via questioning and testimony. As such, VA has substantially complied with the duties set forth in 38 C.F.R. 3.103(c)(2), consistent with Bryant. VA has satisfied its duty to notify in accordance with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159, as any notice defects did not affect the essential fairness of the adjudication of the Veteran's claim. With regard to the duty to assist, service treatment records, post-service treatment records, and records from the Social Security Administration (SSA) have been obtained and considered. As directed in the May 2009 remand, outstanding VA treatment records dated from 2004 forward were obtained. Further, the Veteran was afforded a VA examinations pertaining to his PTSD in September 2006, January 2008, and December 2009, in compliance with the prior remand instructions. While the Veteran has argued that the January 2008 VA examination was inadequate, he was afforded a new VA examination in December 2009. Neither the Veteran nor his representative has alleged any fault with the most recent VA examination. Furthermore, a review of the three examination reports reveals no inadequacies, as all rating criteria were addressed, including the Veteran's symptomatology and the degree of social and occupational impairment. The Board also notes that VA treatment records remain outstanding, as the most recent records in the claims file are dated in May 2010, and the Veteran continued to receive mental health treatment on a weekly basis through at least February 2011. However, he is not prejudiced by the absence of any such records, as only the question of the severity of the Veteran's PTSD for the period prior to December 7, 2009, is currently before the Board, in accordance with the Court's September 2012 Memorandum Decision. Sufficient medical evidence is of record as to this period. Moreover, the Veteran and his wife described essentially the same symptoms during the February 2011 hearing and in May 2013 statements as reflected by the available records, including the most recent VA examination. As such, there is no indication that any outstanding treatment records would help substantiate his claim. For all of the above reasons, the AOJ substantially complied with the prior remand instructions. See D'Aries, 22 Vet. App. at 106. A further remand would serve no useful purpose, as it would unnecessarily impose additional burdens on VA with no benefit to the Veteran. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). VA has satisfied its duties to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceedings. As such, the Veteran will not be prejudiced by a decision on the merits of his claim. II. Analysis VA's percentage ratings are based on the average impairment of earning capacity as a result of service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Evaluation of a mental disorder requires consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. Evaluations will be assigned based on all evidence that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of the examination. The extent of social impairment shall also be considered, but an evaluation may not be assigned based solely on the basis of social impairment. 38 C.F.R. § 4.126. Under 38 C.F.R. § 4.130, all service-connected mental health disabilities are rated pursuant to the General Rating Formula for Mental Disorders. The criteria for a 30 percent rating are: 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 normal conversation), 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). The criteria for a 50 percent rating are: 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. The criteria for a 70 percent rating are: 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. The criteria for a 100 percent rating are: 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. The symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list but, rather, serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating for a mental disorder. In addition to the symptoms listed in the rating schedule, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The DSM-IV provides for a global assessment of functioning (GAF), a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DSM-IV). In this case, the Veteran applied for an increased rating for PTSD in March 2006. As the evidence of record reflects symptoms that warrant different ratings during distinct time periods in the course of this appeal, staged ratings were assigned. See Hart, 21 Vet. App. at 509-10. Specifically, the RO awarded a 30 percent rating for the period prior to December 7, 2009, and a 70 percent rating for the period thereafter. As discussed above, in an April 2011 decision, the Board denied a rating in excess of 70 percent for PTSD for the period beginning December 7, 2009. The Court determined in a September 2012 Memorandum Decision that this issue had been abandoned. As such, only the period prior to December 7, 2009, remains on appeal. Specifically, the Court directed the Board to discuss entitlement to a rating in excess of 30 percent prior to December 7, 2009, to include whether the rating of 70 percent should be applied prior to the date of the VA examination on December 7, 2009. For the reasons set forth below, the Board finds that a rating of 50 percent, but no higher, is warranted for the Veteran's PTSD for the period prior to October 13, 2009; and a rating of 70 percent, but no higher, is warranted beginning October 13, 2009. Preliminarily, the Board notes that the Veteran and his wife have stated that he was afraid to report the true nature of his symptoms to his VA providers and examiners because he did not want to be hospitalized as in the past. However, these statements are inconsistent with the fact that the Veteran did report more severe symptoms at various points for treatment and compensation purposes, and particularly starting in October 2009, as summarized below. Statements made for treatment purposes may be assigned higher probative value because the Veteran had a strong motive to tell the truth in order to receive proper care. Rucker v. Brown, 10 Vet. App. 67, 73 (1997). The Board finds these statements to be more probative, especially given that the Veteran and his wife both indicated to his VA providers and examiners that therapy and medications were helping him at times, but he also specifically sought further therapy for increasing symptoms or severity of depression on several occasions. The Veteran and his wife have also asserted that his VA providers only talked to him for about 10 minutes at a time and did not understand the true nature of his disability. This is inconsistent with the other evidence, as the medical records show that medication management sessions were for approximately 10 minutes, but regular individual psychotherapy and group therapy sessions were at least 45 minutes each. Throughout the period on appeal, the lay and medical evidence of record establishes that the Veteran has had chronically impaired sleep, with frequent nightmares of traumatic events during service, and sometimes night sweats and physical reactions while asleep. Although he reported several times that psychiatric medications improved his sleep, he continued to have problems and recurrent nightmares. The Veteran has also had continuing flashbacks and intrusive thoughts of his experiences in Vietnam with varying frequency, as well as hypervigilance or suspiciousness, exaggerated startle response, avoidance of thoughts or experiences related to Vietnam, and occasional sense of foreshortened future during the appeal. Additionally, the Veteran has had frequent (but not continuous) depressed mood and other symptoms of depression, such as occasionally flat or constricted affect, varying levels of motivation or energy, and varying interest in hobbies or leisure activities (or anhedonia). For example, VA treatment records noted increased depression related to a lack of structure in his day in August 2006, but adequate motivation and energy within normal limits in January 2007. The Veteran then reported being very moody and not wanting to finish projects in April 2007, and treatment records again noted that he was moody after returning from a summer trip in November 2007. He was noted to be in a good mood during therapy sessions from February to April 2008, and again in November 2008 and February 2009, but he reported depressed mood and frequent mood changes in the intervening months. Also, the Veteran reported leisure activities including collecting antique tractors and traveling to buy them, playing golf, and watching television. However, he and his wife complained of him not having the motivation or energy to complete projects such as working on the tractors, and that he would watch television all day long. In August 2006, his VA provider noted that the Veteran remained interested in hobbies and travel but lacked the motivation to make them happen. The September 2006 VA examiner then summarized that the Veteran had good performance recreational and leisure pursuits, but VA treatment records continued to reflect complaints of problems completing projects after that time. The Veteran has had mild memory loss and difficulty concentrating, such as difficulty remembering directions or where he put items such as mail, and forgetting to complete tasks or take pills. The June and July 2005 SSA examiners found mild memory loss and mild difficulties with concentration due to such symptoms, although the Veteran had no objective memory loss with testing during the VA examinations. Other disturbances of motivation and mood included frequent anxiety, or feeling "shaky" inside, with occasional panic attacks. The Veteran has generally denied panic attacks, such as during the September 2006 and September 2008 VA examinations. However, he has been easily angered and frequently irritable, including with road rage during traffic on a regular basis. In May 2008, he described these episodes as making him feel hot with other physical reactions, which the Board notes may have been panic attacks to some extent. Although the Veteran has reported several times that his psychiatric medications helped make him less anxious and irritable, he continued to have frequent anxiety and anger management problems. The Board notes that the Veteran and his wife have asserted that he frequently wants to harm others, such as during episodes of road rage. However, he has repeatedly denied physical violence or homicidal thoughts during VA and SSA examinations and for treatment purposes. The Veteran's wife also testified that, although he is frequently angry, he has never physically harmed her or the children. In his April 2007 notice of disagreement, the Veteran stated that he almost always carries a gun when discussing road rage; however, he reported to his VA provider in April 2008 that he does not carry a gun in his car to avoid using it when angered by traffic. In May 2008, the Veteran indicated that he had thoughts of that he would "get this guy" during episodes of road rage, and he learned strategies to reduce anger. The Veteran and his wife have also asserted that he frequently wants to hurt himself, including suicidal thoughts. For example, during the January 2009 Travel Board hearing, the Veteran asserted that he had suicidal thoughts within the past six months and his wife hid his guns from him, but he had not discussed these thoughts with his provider. Although they are competent to report observable manifestations of his PTSD, the Board finds their statements to this effect to be not credible because they are inconsistent with the medical evidence, including the more probative statements made for treatment purposes. See Rucker, 10 Vet. App. at 73. In particular, the Veteran repeatedly denied suicidal ideation for treatment purposes, including within the few months before and after the Travel Board hearing. Although the Veteran reported frequent thoughts of wanting to hurt himself or that he would be better off dead in a March 2009 primary care screen for depression, he denied suicidal ideation in an April 2009 group therapy session where they discussed a group member who had committed suicide several years earlier. He also repeatedly denied suicidal ideation or thoughts after that time. These statements outweigh the other statements by the Veteran and his wife concerning suicidal thoughts. With regard to relationships, although the Veteran had several prior marriages, he has been married to the same woman throughout the appeal, or since early 2005. He has generally reported a stable and positive marital relationship, as well as with her children, and the Veteran's wife confirmed this during a September 2006 VA examination. He had no contact with his biological family, other than with his sister through attorneys concerning an ongoing legal dispute over their mother's estate. Besides his family, the Veteran had one close friend with medical problems whom he assisted as of September 2006, but few other friends or social contacts. He generally participated well in group psychotherapy, and he was noted to benefit from increased socialization, although there were several times when he participated less due to hearing difficulties. The Veteran has repeatedly reported not wanting to be around others, having low tolerance for people in general with frequent frustration, and having difficulty in crowds, which his wife has confirmed on several occasions. During the September 2006 VA examination, the Veteran was found to have good performance in family role and in social or interpersonal relationships. The January 2008 VA examiner found mild detachment and mild or moderate social withdrawal. There was no indication of impairment of thought process or communication, as the Veteran had adequate speech, logical expression of thoughts and ideas, intact thought process, and no suspected cognitive limitations. Judgment and reasoning were noted to be moderate or good, and he was fully oriented to all spheres. The Veteran denied hallucinations or delusions, and there was no suggestion of psychotic process. There was no evidence of obsessive or ritualistic behavior that interfered with routine activities. Further, there was no grossly inappropriate behavior during the appeal. The Board notes that the Veteran and his wife have asserted that he would not tend to his personal hygiene or other activities of daily living without prompting. However, he was repeatedly noted to have appropriate grooming and hygiene, and to be able to maintain minimal personal hygiene and other basic activities of daily living. In a July 2005 evaluation for SSA, the Veteran was found to have mild restriction of activities of daily living due to his mental health. The Veteran and his wife also reported at that time that his main limitations were due to physical complaints at that time. Concerning occupational impairment, the Veteran has been retired since 2004, and he has been granted a total disability based on individual unemployability (TDIU) based on the service-connected PTSD and hearing loss effective as of December 7, 2009. Although he and his wife have reported at various times that he was unable to work and retired due to his PTSD, the Board finds these statements to be not credible because they are inconsistent with the other, more contemporaneous evidence. In particular, the Veteran and his wife reported for his SSA claim in 2005 and 2006 that his primary difficulties were due to physical complaints such as shortness of breath. They did not assert that his PTSD was involved in his retirement or termination of employment at that time, and SSA disability benefits were granted based on physical conditions, with no reference to any mental health symptoms in the June 2006 decision. Additionally, SSA mental health evaluators indicated in June 2005 and July 2005 that the Veteran's mental health was "not severely limiting" to his occupation. Further, a January 2008 VA examiner concluded that the Veteran was not unemployable due to PTSD. Indeed, VA treatment records reflect that the Veteran held a temporary job for one month from February to March 2009, showing that he was capable of positive interaction of an occupational nature at that time. As such, although the Veteran's PTSD symptoms likely resulted in occupational impairment due to conflicts with coworkers as a result of his frequent irritability and other symptoms, he was not unemployable or totally occupationally impaired. The Veteran's assigned GAF scores ranged from 55 to 65 for the period prior to October 13, 2009. See September 2006 VA examination report (GAF of 65, summarized as moderate impairment due to PTSD); January 2007 VA treatment record (GAF of 55); January 2008 VA examination (GAF of 60, summarized as occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks due to PTSD symptoms); May 2008 VA treatment record (GAF of 56); April and May 2009 VA treatment records (GAF of 63). A GAF score of 51 to 60 indicates the presence of moderate symptoms (e.g., flat affect, circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). A GAF score of 61 to 70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but that the individual generally functions pretty well with some meaningful interpersonal relationships. See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). These scores must be considered together with the other evidence of record to arrive at the appropriate disability rating. The Board observes that several examiners and providers indicated prior to October 13, 2009, that the Veteran's symptoms were considered controlled, at a baseline level, and relatively stable with various psychiatric medications. See, e.g., September 2006 and January 2008 VA examination reports; March 2007, March 2008, January 2009, and March 2009 VA psychiatric treatment records. Nevertheless, reviewing all of the lay and medical evidence, it appears that these notations were meant to signify that the Veteran's symptoms or overall severity of disability had not increased from his personal baseline level, which included chronic sleep impairment, disturbances of motivation and mood including frequent depression and anxiety, irritability and anger outbursts with road rage, mild memory loss such as forgetting to complete tasks, and difficulty in establishing and maintaining effective relationships. As discussed above, although the Veteran has maintained a stable relationship with his fourth wife, he is fairly socially isolated and has only a few friends outside of the family. These symptoms all support a 50 percent rating for reduced reliability and productivity. Further, although there were some periods of only mild impairment prior to October 13, 2009, such periods were relatively short and not so distinct as to warrant a continued rating of 30 percent. Rather, the Board will resolve doubt in the Veteran's favor to find that he had relatively continuous moderate social and occupational impairment with reduced reliability and productivity during this period. The Board also notes that the Veteran began to report increased symptoms for treatment purposes in May 2009, including more frequent flashbacks and nightmares, depression, irritability, and difficulty controlling anger. Nevertheless, the evidence does not indicate that these symptoms resulted in an overall higher level of social or occupational impairment at that time. Rather, the Veteran was continued on his previous medications and assigned a relatively high GAF score of 63 at that time. In contrast, the Veteran reported worsening symptoms of depression and anger on October 13, 2009, which the December 2009 VA examiner referenced in finding severe overall impairment with a GAF score of 50, as discussed below. As such, resolving all reasonable doubt in the Veteran's favor, the Board finds that his PTSD resulted in occupational and social impairment with reduced reliability and productivity for the period prior to October 13, 2009, warranting a rating of 50 percent. However, the evidence does not more nearly approximate the criteria for the next higher rating of 70 percent for this period, as it does not reflect social and occupational impairment with deficiencies in most areas due to PTSD. Although the Veteran had some symptoms contemplated by higher ratings, his overall disability picture does not meet the criteria for the next higher rating. See 38 C.F.R. § 4.7. For the period beginning October 13, 2009, the Board finds that the evidence warrants a higher rating of 70 percent, but no higher. In this regard, the December 2009 VA examiner noted that the Veteran had been seen for worsening symptoms in October 2009. The examiner summarized a current functioning level of severe impairment with a GAF score of 50 for the current time frame. Further, the Veteran reported in March 2010 that he had been having much worse symptoms of depression for approximately five months, stating that he did not want to do anything and had gained 30 pounds. This would be consistent with his treatment on October 13, 2009, for worsening symptoms of depression, when he stated that he did not want to get up in the morning or leave the house. The Veteran also reported worsening symptoms of anxiety, including that he could not sleep because his mind was racing. His medications were adjusted at that time due to the reports of increased symptoms. Resolving doubt in the Veteran's favor, this shows nearly continuous panic or depression affecting the ability to function independently, appropriately, and effectively as of October 13, 2009. Additionally, as discussed in the prior Board decision concerning a 70 percent rating from December 7, 2009, forward, the Veteran has been assigned GAF scores of 50 and 52 from December 2009 forward, and the VA examiner and treating providers have summarized that he had severe symptoms of PTSD during that period. This is a noticeable and sustained difference from the Veteran's prior level of functioning, which warrants a higher rating of 70 percent. The Board notes that the VA provider recorded a GAF score of 71 on October 13, 2009. Generally, a GAF score of 71 to 80 indicates that any symptoms are transient and expectable reactions to psychosocial stressors, or no more than slight impairment in social, occupational, or school functioning. See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). However, such a GAF score does not appear to be an accurate representation of the Veteran's level of disability at that time based on the recorded mental health symptoms, other assigned GAF scores, and summaries of his level of functioning. As such, this may have been a typographical error. Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that his PTSD symptoms increased in degree of social and occupational impairment so as to more nearly approximate the next higher rating of 70 percent as of October 13, 2009. In other words, while the Veteran continued to have similar symptoms, they became more severe so as to result in deficiencies in most areas, including near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively at that time. See 38 C.F.R. §§ 4.7, 4.130, DC 9411. However, a higher schedular rating of 100 percent is not warranted for any period. In this regard, although the December 2009 VA examiner summarized that the Veteran had total occupational and social impairment due to PTSD, this was based in large part on the Veteran's reports that he was told to resign in 2004 due to interpersonal difficulties with coworkers and supervisors as a result of anger problems. As discussed above, this is inconsistent with the other evidence of record, which is also more contemporaneous to the time of the Veteran's retirement, and which indicates that the Veteran retired due primarily to his physical limitations. The Board finds such evidence to be more probative and to outweigh the other statements as to the reasons for the Veteran's retirement. Further, the Veteran continued to have some effective social relationships and interactions, including with family, a few friends, and other veterans during group therapy. As such, the evidence does not establish total occupational and social impairment due to PTSD at any point. In making these determinations, the Board has considered all potentially applicable rating codes, and there is no basis to assign a higher rating than those assigned herein under any alternate diagnostic code. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Although staged ratings have been assigned, no further staging is warranted, as the Veteran's manifestations of PTSD were relatively stable during the respective periods on appeal. See Hart, 21 Vet. App. at 509-10. Additionally, the Board has considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). In this regard, the Veteran's PTSD symptoms and, particularly, his resulting social and occupational impairment, are fully contemplated by the schedular rating criteria. Therefore, the rating schedule is adequate, and it is not an exceptional or unusual disability picture. Moreover, there are no related factors such as marked interference with employment or frequent periods of hospitalization during the period on appeal. While PTSD affected the Veteran's employment prior to retirement in 2004, including occasional arguments with coworkers, such interference is addressed by the assigned ratings. The ratings are considered adequate to compensate for considerable loss of working time from exacerbations proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Accordingly, it is not impracticable to apply the schedular standards. Referral for consideration of an extra-schedular rating is not necessary in this case. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). In a September 2010 rating decision, the AOJ granted a TDIU effective December 7, 2009, based on the effects of the service-connected hearing loss and PTSD. The Veteran has not requested appellate review of any aspect of that decision, to include the effective date. As such, no further discussion of a TDIU is necessary. The Veteran has been granted partial increased ratings herein as explained above based, in part, on application of the benefit of the doubt doctrine. Nevertheless, the preponderance of the evidence is against a rating in excess of 50 percent for PTSD for the period prior to October 13, 2009, and a rating in excess of 70 percent for the period beginning October 13, 2009. As such, the benefit of the doubt doctrine does not apply, and the Veteran's claim must be denied in this regard. 38 C.F.R. § 4.3. ORDER For the period prior to October 13, 2009, a disability rating of 50 percent, but no higher, for PTSD is granted. For the period beginning October 13, 2009, a disability rating of 70 percent, but no higher, for PTSD is granted. ____________________________________________ JOAQUIN AGUAYO-PERELES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs