Citation Nr: 1324191 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 09-09 237 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Wade R. Bosley, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD D. M. Casula, Counsel INTRODUCTION The Veteran had active service from July 1968 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) from a November 2007 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA) which granted service connection for PTSD, and assigned a 50 percent rating, effective February 22, 2006. A January 2009 rating decision granted an earlier effective date of November 9, 2005, for the grant of service connection for PTSD and the assignment of a 50 percent rating. The Veteran continued the appeal for a higher rating. In August 2009, the Veteran testified at a Travel Board hearing at the RO before the undersigned Veterans Law Judge. At the hearing, he testified he was currently unemployed, but actively looking for work, and expressly indicated he was not seeking a total rating based on individual unemployability due to service-connected disability (TDIU) at the time. Subsequent to the hearing, the Veteran has continued to maintain that his PTSD affects his ability to obtain and maintain employment, but has not alleged that his PTSD causes unemployability. A claim for TDIU is part of an increased rating claim when the claim of TDIU is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the Board finds that a claim for a TDIU rating has not been raised by the record because the Veteran has said he was not seeking TDIU. In January 2010, the Board remanded this claim and the Board is satisfied there has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT The Veteran's PTSD has been manifested by no more than reduced reliability and productivity due to such symptoms as: anxiety, disturbances of motivation and mood, impairment of short term memory, occasional reports of suicidal ideation, but no plan or intent, and difficulty in establishing and maintaining effective work and social relationships, and other symptoms not explicitly listed in the applicable rating diagnostic code including, but not limited to, chronic sleep problems, insomnia, nightmares, depression, anxiety, flashbacks, intrusive thoughts, isolating behaviors, hypervigilance, concentration difficulties, and anger issues. CONCLUSION OF LAW The criteria for an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (DC) 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and assist claimants in substantiating claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of 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. 38 C.F.R. § 3.159(b)(1) (2012). The notice should be provided prior to an initial 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). The notice requirements apply to all five elements of a service connection claim: (1) Veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473 (2006). If complete notice is not provided until after the initial adjudication, any timing error can be cured by subsequent legally adequate notice, followed by readjudication of the claim, as in a statement of the case or supplemental statement of the case. Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing an error is harmful or prejudicial falls upon party attacking agency determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the notice requirement is for generic notice of the type of evidence needed to substantiate the claim, which is evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, and general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Board finds that the duty to notify was satisfied by a May 2007 letter that fully addressed the notice elements. Because the appellate issue of entitlement to assignment of an initial compensable rating is a downstream issue from that of service connection for which the May 2007 notice letter was duly sent, further notice is not required. VAOPGCPREC 8-2003 (2003), 69 Fed. Reg. 25180 (2004). This appeal is from the initial rating assigned with the grant of service connection. Once a decision awarding service connection, disability ratings, and effective dates has been made, statutory notice has served its purpose, and its application is no longer required because the claim has already been substantiated. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In addition, a January 2009 statement of the case provided him with notice of the criteria for rating PTSD, including what the evidence showed, and why the current rating was assigned. The Veteran has had ample opportunity to respond and supplement the record, and provided testimony in this matter in August 2009. He is not prejudiced by this process and he does not allege that notice in this case was less than adequate or that he is prejudiced by any notice deficiency. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Goodwin v. Peake, 22 Vet. App. 128 (2008). The Board also notes that in the May 2007 letter, the Veteran was advised of how disability ratings and effective dates are assigned. He has not demonstrated any error in notice and the Board concludes that all required notice has been given to the Veteran. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claim. The RO has obtained all identified and available service and post-service treatment records for the Veteran. Further, the Veteran underwent VA examinations in February 2005, October 2007, and in March 2010 to assess the severity of his PTSD. Each of those VA examinations included a review of the claims folder and a history obtained from the Veteran. In addition, examination findings were reported, with diagnoses and opinions, which were supported in the record. Those examination reports are therefore adequate for rating purposes. Barr v. Nicholson, 21 Vet. App. 303 (2007). Additionally, in August 2009, the Veteran was provided an opportunity to set forth his contentions at a hearing before the undersigned Veterans Law Judge. It appears that all obtainable evidence identified by the Veteran relative to his claim has been obtained and associated with the claims folder, and that neither he nor his representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. The Board concludes that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board concludes that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim. No useful purpose would be served in remanding this matter for more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). On a VA examination in February 2005, the Veteran reported having nightmares of Vietnam two to three times per week. He felt anger when he came back from service, but denied any exaggerated startle response. The examiner indicated that the Veteran did not give any other symptoms of PTSD except nightmares, anger, and feeling different from others. It was noted that he had seen a psychiatrist in prison for a sleep problem. He had been in prison for 22 years and was released the previous October. He had never attempted suicide and had never seen a psychiatric on a regular basis. He lived with his sister and her husband, and reported that when he was released from prison he worked as a computer technician, but was laid off three weeks previously and hoped to return. On mental status examination, he was alert, oriented, and adequately groomed. He had normal psychomotor activity, good eye contact, and good concentration and attention. His mood was almost euthymic and his affect was broad. His speech was of normal rate and volume, and his thought process was goal directed, logical, and relevant. There was no suicidal or homicidal ideation. His judgment was found to be impaired by history and his insight was fair. A Global Assessment of Functioning (GAF) score of 70 was assigned. The examiner concluded that the Veteran did not meet the criteria for PTSD, noting he did mention a few symptoms, but did not fully meet the criteria. In a statement dated in February 2005, the Veteran reported that he had repeated nightmares, difficulty sleeping, and a daily struggle to function with a sleep deficit. He claimed that the lack of sleep affected many aspects of his life. VA treatment records show that in February 2006, the Veteran requested treatment for PTSD, admitting he had never been diagnosed with PTSD but complained of insomnia, nightmares, and poor concentration. He reported that while in prison he was treated for psychiatric problems. He also reported having nightmares about his combat experiences in Vietnam, intrusive thoughts about killing people during the Vietnam war, and had to avoid watching current war reports. He denied problems with depression. On mental status examination his mood was euthymic, his affect was congruent with his mood, his speech was within normal limits, he had no psychomotor agitation or retardation, and he had no complaints of memory loss. He had no visual or audio hallucinations, no delusions, and no suicidal or homicidal ideation. He reported he felt alert all the time, and had no problems working night shift and only sleeping four to five hours during the day. He was not interested in a prescription, but was interested in counseling. In March 2006 he started attending group psychotherapy for PTSD. VA treatment records show that in June 2006 the Veteran was seen for the first time for treatment of possible PTSD-related mental health problems. It was noted that he was asking for help with sleep, but by assessment he was also noted to have psychosis, anger issues, suicidal thoughts, flashbacks, nightmares, and significant problems sleeping. He was also noted to have a history of violence towards others, flashbacks, auditory and visual hallucinations, and paranoia. He reported having trouble with sleep since he returned from Vietnam. He reported being in prison three times, and most recently from 1982 to 2004 for robbery and shooting someone. It was noted that he had not consciously had a history of suicide attempts, but that much of his behavior had been self-destructive and that some members of his family still were afraid to be in a car with him, even though he believed he drove well. He reported that in prison he was getting "stuff" to sleep, and that lasted 10 to 12 years, but he had no other treatment. He was working as a computer technician. He reported no real issues with his family, and that he was still good with his family, except that some did not want to be in car with him when he drove. On mental status examination the Veteran was well groomed, with normal motor/psychomotor activity, normal speech, and no problems with thought content or processes. He reported he was depressed at times, but not all the time. He reported having visual hallucinations, saying he always saw more than other people see. He reported he was more alert than he needs to be, was more attentive to sounds, and had a constant level of paranoia, but no longer carried a weapon. He reported anger problems, but had no suicidal ideation. He never had thoughts of harming others, without a reason, and no regular homicidal ideation. He had problems with attention and concentration at times, and had problems with short term memory, which was worse if he had not slept for awhile. His recent judgment was good and insight was fair. The diagnosis was PTSD vs. depression and psychosis. A GAF score of 55 to 60 was assigned. VA treatment records further show that in August 2006, the Veteran reported that his medication was working, his depression had improved, and his anger and rage were less. His night problems had improved, but he was still hypervigilant. He had no suicidal thoughts, and reported he had anger but stayed weapon free. He still had paranoia, and his hallucinations were much less and muted. Mental status examination was essentially negative, except for some minor issues with short term memory. The diagnosis was PTSD with psychosis, and the GAF score was 55 to 60. In September 2006, he had an unstable mood sometimes, paranoid, avoidance, isolating behavior, and mild visual hallucinations. He reported being anxious. In a November 2006 VA psychology treatment record, it was noted that the Veteran lived alone, worked nights, and was personal and cooperative on interview. On a psychological evaluation in November 2006, he underwent several tests which revealed he reported minimal distress despite the presence of some fairly elevated levels of symptomatology; he was a very anxious individual who recognized the minimal support and contact he had with others, and his poor interpersonal interactions; and he had had chronically depressive features. A psychiatric medication management note in November 2006 shows that the Veteran reported that the medication was helping him shut down so he could sleep, and that he now had satisfactory sleep. He still had some nightmares, but less. His energy was low, and he had no suicidal or homicidal ideation. His mood was stable, but he got angry at times. He still had some visual hallucinations when he was really tired. He was still somewhat paranoid and alert. His mental status examination was essentially negative, except for some minor problems with short term memory. In May 2007, he reported that sometimes he felt pretty decent, and his energy overall was not bad. He still had some paranoid, partly due to him sleeping during the day and partly because he liked shutting the world out. He was not having auditory hallucinations, but his hearing was more sensitive. He had anxiety when he was paranoid. Mental status examination was negative except for some short term memory problems. He continued to attend regular group psychotherapy sessions. On a VA examination for PTSD in October 2007, it was noted that the Veteran was treated with group therapy and an anti-psychotic medication which improved his sleep. He had a depressed mood for days at a time, less energy or motivation, and a variable appetite and energy level. He worked a lot, and had friends and was outgoing and sociable. He had four children, one son was deceased, one son who he hardly had contact with, one daughter who he talked to by phone every one to two months, and another daughter who he had hardly talked to since March 2007. He was dating a special friend for about two years, and their relationship was going well. He had regular contact with one of his sisters. He had a few acquaintances and talked with co-workers, but did not spend time with people outside of work. His leisure pursuits included computers and watching movies. He denied a history of suicide attempts. On objective examination, his speech was unremarkable, clear, and coherent. His affect was constricted and somber. His mood was apprehensive. He was oriented and had no problems with his thought process. He reported a chronic history of sleep problems and sometimes slept more with medication. He had no inappropriate behavior, no obsessive or ritualistic behaviors, and no panic attacks. There was no presence of homicidal or suicidal thoughts. While he might have thoughts of wanting to hurt others, he denied a specific target or intent to act on those thoughts. He had poor impulse control. He maintained minimal personal hygiene. He denied hallucinations. He did not did not present as overtly psychotic or with a thought disorder, but did appear overly vigilant and distrustful. His memory was normal. He reported nightmares about Vietnam, sometimes once a month and sometimes several days in a row. There were times he woke up and felt extremely angry, and reported intrusive recollections, thoughts, and images. He avoided discussions or conversations about his Vietnam experiences, and was not comfortable in crowds. He attended some events, but avoided others. He could be extremely upset and no one knew because he was not emotional on the exterior. He reported he lost his fear after the war, and had been told by family members he drove recklessly. He had difficulty getting close to people and making friends. He reported having anger "beyond human comprehension" and felt angry most of the time, but felt like it was controlled. He reported being on guard or on edge most of the time. He looked out windows and blinds a lot, but did not startle easily. He had PTSD symptoms most days, with periods of remission for a few days in a row. He reported that his girlfriend and family helped him cope, and that he only associated with his girlfriend, her family, and other veterans. He felt he was barely hanging on to his job because he got frustrated with others, but was able to work independently and alone, which helped. He claimed his sleep decreased his ability to function, and he felt fatigued with concentration problems due to poor sleep. He was employed full time doing warranty repair for two to five years, and had lost four weeks in the last year due to a heart attack, vacation, and calling in every once in awhile because he did not want to go or want to leave the house. The diagnoses included PTSD, chronic, moderate to severe, and depressive disorder. A GAF score of 45 to 50 was assigned. Further, on the October 2007 VA examination, the examiner opined that the Veteran's PTSD and depressive disorder symptoms were causing moderate to severe impairment in his functioning. With regard to changes in his function status and quality of life since his last examination, the Veteran reported he worked alone, which helped, and that he got angry and irritable with the people around him. He had a solid relationship with his girlfriend and her family, but did not have many friendships or social relationships otherwise. His social functioning was impacted by his symptoms and history of incarceration for several years. The examiner opined that his prognosis was fair, and that he had noted some improvement with treatment, but continued to have moderate to severe impairment. The examiner opined there was not total occupational and social impairment due to PTSD signs and symptoms, but that PTSD resulted in deficiencies in his judgment, thinking, and mood, and there was reduced reliability and productivity in his work functioning. In August 2009, the Veteran testified, and submitted evidence indicating, that since his October 2007 examination, he had worked for at least seven different companies, all of which had laid him off due, at least in part, to his PTSD symptoms. He testified he had experienced difficulty getting work "on a regular and consistent basis" due to his PTSD-induced concentration problems, difficulty getting along with others, and social withdrawal tendencies. He also testified that, on occasion, those tendencies had made his former co-workers afraid of him. He stated that he was currently unemployed, but actively looking for work, and had been repeatedly turned down for interviews or dismissed from jobs after a short time. He testified that due to his efforts to obtain employment and be available for jobs during the day, he had to stop going to a PTSD support group, which had helped alleviate his symptoms. VA treatment records, however, showed that the Veteran continued to attend group psychotherapy sessions through December 2009. In February 2010, he was seen for medical management and reported he was doing "so so". His mood was okay, his energy was good, but he had nightmares, intrusive thoughts, and flashbacks, but not as often. Mental status examination was negative. Later in February 2010, it was noted that he wished to seek treatment for PTSD but was unable to due to work, but he indicated that when he was not working he would start individual therapy. On the VA examination in March 2010, it was noted that the Veteran's mental disorder was treated with an anti-manic medication which improved his mood. He was not involved with group or individual therapy. He was widowed and had three children, one of which he was estranged from. He had few social contacts and limited leisure time pursuits. He worked for a temporary agency, but had missed some work due to feeling overwhelmed. He had contact with some family, but few friends. On objective examination his psychomotor activity was unremarkable, his speech was spontaneous, and he was oriented, and cooperative to the examiner. His affect was normal, but mood was hopeless. His attention and concentration were intact. His thought process was unremarkable, but his thought content involved ruminations. He had no delusions or hallucinations. He reported poor sleep due to nightmares. It was noted that his inappropriate behavior involved driving aggressively. He had no obsessive or ritualistic behaviors, no panic attacks, and no homicidal or suicidal thoughts. His impulse control was fair, and he was not easily angered but, when pushed, felt rage. He maintained minimum personal hygiene, and had no problems with activities of daily living. His remote memory was mildly impaired, and there were gaps in his memory for the distant past. However, his recent and immediate memory were normal. It was noted that his PTSD symptoms were chronic with no remissions, occurred daily, and were at a moderately severe level. He reported he was unable to relax and had frequent nightmares and intrusive memories which reduced the quality of his life. He was currently employed doing temporary work. He had worked three different jobs, and lost four weeks of work, in the last twelve months and had missed work due to periods in which he felt overwhelmed. The diagnoses included PTSD, and a GAF score of 51 was assigned. In summary, the VA examiner in March 2010 indicated that the Veteran's changes in functional status and quality of life since the last examination involved employment performance, social and interpersonal relationships, and recreation and leisure pursuits. It was also noted that he had hyperarousal, numbing and re-experiencing, which had led to missed work, difficulties getting along with others on the job, and few social contacts, which had led to few leisure time pursuits and poor quality of life. He also had a history of legal problems and lengthy incarceration which limited his social and work function. The examiner opined that there was not total occupational and social impairment due to PTSD signs and symptoms, but that PTSD resulted in deficiencies at work and in his mood, but not in judgment, thinking, or family relations. The examiner noted that the Veteran's mood was distressed secondary to PTSD, and that he had lost jobs, and while able to work periodically, had missed days due to PTSD symptoms. With regard to employability, the examiner opined that the Veteran's PTSD symptoms, especially hyperarousal, had interfered with work function and led to lost jobs with some episodes of missed work, but they "most likely do not entirely on their own preclude" him from being able to engage in some form of meaningful work activity. VA treatment records showed that in March 2010, a GAF score of 54 was assigned. In April 2010, the diagnosis was PTSD with depression and possible psychosis. It was noted that the Veteran had nightmares, but no suicidal or homicidal ideations. In July 2010, it was noted that his mood varied, he was unemployed again but awaiting a new assignment that would start that week, was active in therapy, had poor sleep and nightmares, but had no suicidal or homicidal ideation. On mental status examination, the Veteran was found to be alert, well groomed, and with a varying mood. His affect was appropriate, and he had no delusions. He had some flashbacks, but no suicidal or homicidal ideations, and his thoughts were logical and goal directed. In August 2010, he indicated he was frustrated trying to maintain employment, and felt that he may have been let go several times when it was discovered he had a criminal record. He was also seen for complaints of teeth pain, but was otherwise healthy and worked out regularly and rode his bike daily. He reported having nightmares at least once a week. In September 2010, he was seen for individual psychotherapy, and it was noted that he was not a danger to himself or others. His strengths were listed as: insightful, aware of illness; expressed desire/motivation to change; and supportive family and/or friends. His treatment plan problems, listed by priority, included intrusive thoughts and nightmares. Received from the Veteran in May 2011 was a letter in which he maintained that he should be entitled to a 70 percent rating for his PTSD. He indicated he worked for a "temp service" in a warehouse at nights, which he indicated was hard work for a man his age, but that he had to continue to try to work. He claimed that in 2008 he had eight different jobs, in 2009 he had five different jobs, and had had too many periods of unemployment to count. Of his three surviving children, he had no contact with two of them, claiming he did not know what to say to them or how to explain. In September 2011, it was noted that he had not followed up with psychiatry since September 2010. He denied suicidal and homicidal ideation, but had a positive PTSD screen. As of November 2011 he worked in a warehouse, and in November 2012 and again in January 2013, it was noted that he worked in a warehouse. Disability ratings are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1, 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). When rating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating 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. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). The Veteran's PTSD has been rated under the General Rating Formula for Mental Disorders, under which a 50 percent rating is warranted 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 (for example, 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. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2012). A 70 percent rating is warranted for 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. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2012). A 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2012). The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited. Rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition to the applicable rating criteria, in rating the Veteran's PTSD, the Board will also consider the GAF scores assigned and the definition of those scores. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (1994) (DSM-IV). The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. 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 rating issue. The GAF scores must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. 38 C.F.R. § 4.126(a) (2012). The Veteran contends that his PTSD has been more disabling than currently rated. PTSD has been rated as 50 percent disabling throughout the appeal period, effective November 9, 2004. He has reported that his PTSD caused him to suffer various symptoms including depression, anxiety, chronic sleep problems, insomnia, nightmares, flashbacks, intrusive thoughts, isolating behaviors, hypervigilance, concentration difficulties, and anger issues. With regard to occupational impairment, the record shows that he has worked at numerous jobs, including temporary work and night shifts, during the course of the appeal, and although he has clearly had difficulty with employment, he has maintained periods of employment, and his work difficulties do not appear to be solely a result of PTSD, as his history of incarceration has also been mentioned as a problem with employment. After reviewing the evidence of record the Board finds that, although there may be or may have been some evidence of some of the criteria required for a rating of 70 percent, and comparable symptoms, the competent medical evidence and his reported symptoms, do not show that the manifestations of his PTSD more closely approximate the criteria necessary for a higher rating. 38 C.F.R. § 4.7 (2012). The Board will discuss separately each of the criteria required for a 70 percent rating. In that regard, although some of the Veteran's recorded symptoms are not specifically provided for in the Rating Schedule, such as nightmares or flashbacks, the symptoms listed at 38 C.F.R. § 4.130 are not an exclusive or exhaustive list of symptomatology which may be considered for a higher rating claim. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The criteria listed in Diagnostic Code 9411 and the General Formula for Rating Mental Disorders, for a 70 percent rating, include occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. In this case, the Veteran is not attending school, so that is not a factor for consideration. With regard to work, the Board notes that, although the Veteran's PTSD has no doubt affected his employment throughout the appeal period, the fact remains that he has continued to obtain employment opportunities, and most recently has worked in a warehouse. Although he attributes his difficulty obtaining and maintaining employment solely to PTSD symptoms, the evidence of record does not fully support that contention, as he was laid off on occasion, and the VA examiner in 2010 opined that the Veteran's PTSD symptoms had interfered with work but did not entirely on their own preclude employment. Moreover, with regard to social impairment, the Board notes that, while the Veteran has reported he isolates himself and does not have many friends, the record shows that he has maintained to some relationships with children, his family, his girlfriend, and other veterans. With regard to the Veteran's judgment, thinking, and mood, the Board notes that impairment of his mood has been shown at various points in the record, at other times he was euthymic and had a stable mood, and his mood was noted to be improved with medication. With regard to judgment and thinking, at most, minimal to no impairment of each has been shown by the objective record. VA treatment records and the VA examination report show that he has had good judgment, and his thought process has been within normal limits. With regard to symptoms needed to warrant a 70 percent rating, the Board notes that the criteria for rating mental disorders list a variety of symptoms that would support each rating. However, the list is not exhaustive. The Board notes that VA treatment records show that with the exception of once or twice, the Veteran has consistently denied having suicidal ideation. There has been no report by the Veteran or finding of any obsessional rituals which interfere with routine activities. While he has reported being on alert and hypervigilant, he has not described any obsessional rituals that interfere with his activities. On examination, the Veteran's speech has consistently been found to be normal. While he has reported having anxiety, primarily caused by paranoia, those symptoms have never been show to rise to the level of affecting his ability to function independently, appropriately, and effectively. While the Veteran has reported having anger issues, being sensitive to noises, and problems with driving, he has also indicated that he has impulse control and no longer carries weapons. In VA treatment records and on VA examination reports the Veteran has consistently been found to be alert, oriented, and adequately groomed. At no time has there been any finding of, or even approximating, spatial disorientation or neglect of personal appearance and hygiene. While the Veteran has, by his own report, had difficulty in adapting to stressful circumstances at work, he has nonetheless been able to maintain periods of employment and has continued to seek employment, even when laid off from other work. In addition, an inability to establish and maintain effective relationships has not been shown. To the contrary, the Veteran has maintained relations with some family members, a girlfriend, and other veterans. In summary, the findings in such areas as work, family relations, judgment, thinking, and mood do not show that the Veteran has deficiencies in most areas, so as to support the assignment of a 70 percent rating. While he may have had some problems in some of those areas, he has for the most part not had problems (or had minimal problems) in these areas. Rather, it appears that his PTSD manifestations more nearly approximate the criteria for a 50 percent rating. 38 C.F.R. § 4.7 (2012). The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his psychiatric condition, and acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned rating reflects. Medical evidence is generally required to address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for those purposes. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a) (2012); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, the competent medical evidence offering detailed and specific determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the PTSD symptoms on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The Board also notes that the GAF scores assigned in VA treatment records and on the VA examination reports have ranged from 45 to 70 during the appeal period. Even considering that wide range of GAF scores, which evidence at least at some point serious symptoms and serious to major impairment, for reasons set forth herein, he was never shown to have PTSD symptomatology of such severity so as to warrant a 70 percent rating. Moreover, most recently, his GAF scores have been 51 and 54 (in March 2010), which suggests moderate symptoms or moderate impairment in social or occupational functioning. Further, when his various GAF scores are considered together with other findings in the medical evidence, the Board finds that the criteria for a rating in excess of 50 percent have not been met. With consideration of the Veteran's complaints, symptoms, and clinical findings of record, the Board concludes that his PTSD manifestations do not approximate the criteria for a 70 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Accordingly, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's PTSD meets, or more nearly approximates, the criteria for a 70 percent rating at any point. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Thus, he is not entitled to an initial rating in excess of 50 percent for his PTSD, and there is no reasonable doubt to resolve in his favor. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). The Board also finds that the Veteran's PTSD does not warrant referral for consideration of the assignment of an extra-schedular rating at any point during the appeal period. In exceptional cases where schedular disability ratings are found to be inadequate, consideration of an extra-schedular disability rating is made. 38 C.F.R. § 3.321(b)(1) (2012). There is a three-step analysis for determining whether an extra-schedular disability rating is appropriate. First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. 38 C.F.R. § 3.321(b)(1) (2012); Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the Veteran's disability picture due to his service-connected PTSD is adequately contemplated by the rating schedule. The rating criteria take into account social and occupational functioning in assessing the severity of his PTSD, and provide for a greater rating for more severe impairment. The record shows that he has maintained periods of employment, and while he has claimed that his PTSD affects his ability to work, the rating criteria for PTSD reasonably describes his disability level and symptomatology. Thus, the evidence does not show that the rating criteria are inadequate and referral for the assignment of an extraschedular disability rating are not met. 38 C.F.R. § 3.321(b)(1) (2012); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER An initial rating in excess of 50 percent for PTSD is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs