Citation Nr: 1324523 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 05-18 384 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with anxiety reaction. REPRESENTATION Appellant represented by: Kenneth A. Carpenter, Attorney at Law ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran had active military service from January 1959 to June 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a September 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The Board notes that the Veteran requested and was scheduled for a video conference hearing before a Veterans Law Judge, but did not appear for the hearing. A report of contact dated in September 2009 indicates that the Veteran was contacted regarding his hearing request, during which conversation the Veteran indicated his desire to withdraw his hearing request. Accordingly, the Veteran's request for a hearing before a member of the Board is considered withdrawn. 38 C.F.R. § 20.704(d), (e) (2012). The instant matter has several times been previously before the Board. Most recently, in April 2012, the Board granted entitlement to a disability rating of 50 percent, effective from July 25, 2001. (Previously, the Veteran had been assigned a rating of 30 percent for his service-connected psychiatric disability, effective from July 25, 2001.) Thereafter, the Veteran filed an appeal to the United States Court of Appeals for Veterans Claims (Court). In January 2013, the Veteran's representative and VA's General Counsel filed a Joint Motion for Remand (JMR) with the Court to vacate that portion of the Board's April 2012 decision that had denied entitlement to an evaluation in excess of 50 percent for the Veteran's service-connected psychiatric disability, which motion was granted by the Court that same month. The basis for the JMR included the Board's failure to address the Veteran's contention that VA had unlawfully severed his protected rating for a service-connected anxiety disorder. FINDINGS OF FACT 1. The Veteran's PTSD with anxiety reaction has been manifested by such symptoms as irritability, sleep issues, anger outbursts, depressed mood, diminished concentration, panic attacks, heightened startle response, and decreased concentration, anxiety and feelings of uneasiness, and forgetfulness, which results in a moderate impact on social and occupational functioning. 2. The symptom manifestations of PTSD and anxiety reaction overlap and their rating criteria are identical. 3. The Veteran's psychiatric disability is not manifested by occupational and social impairment with deficiencies is most areas due to symptoms of the kind listed in the criteria for a 70 percent rating, or others of similar severity, frequency or duration 4. Total occupational and social impairment has not been shown. CONCLUSIONS OF LAW 1. Entitlement to separate disability ratings for anxiety reaction and PTSD are not warranted. 38 C.F.R. § 4.14 (2012). 2. The criteria for a rating in excess of 50 percent for PTSD with anxiety reaction have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance At the outset the Board notes that in its April 2012 decision, the Board determined that all requisite duties to notify and assist had been complied with, to include assisting the Veteran by providing him with an adequate VA examination. In that decision, the Board pointed out that in January 2011, the Veteran's attorney received a copy of the most recent VA examination report, which was dated in February 2009, after which he submitted no additional argument regarding the adequacy of that examination. The Board indicated that although an extended period of time had gone by since the February 2009 VA examination, neither the Veteran nor his attorney had asserted, nor did the evidence demonstrate, that the Veteran's symptomatology had worsened or undergone some material change since the February 2009 VA examination. The Board thus found that a new examination was not warranted. Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination). Notably, the parties' JMR includes no reference to the Board's findings in these regards, nor does the Court's order indicate vacatur of that portion of the Board's decision that found compliance with VA's duties to notify and assist. Furthermore, after the matter was returned to the Board, the Veteran was given 90 days to submit any additional argument or evidence. In June 2013, the Veteran's attorney submitted argument in support of the Veteran's claim. Nowhere in that submission does the Veteran's representative argue that the evidence currently of record is insufficient to rate the Veteran's psychiatric disability, to include alleging that the Veteran's psychiatric disability has increased in severity since the February 2009 VA examination was conducted. Similarly, the evidence of record does not demonstrate that the Veteran's symptomatology has worsened and undergone some material change since its April 2012 decision. Thus, although an extended period of time has gone by since the last VA examination, a new examination is not warranted because there is no indication that the evidence of record is insufficient to evaluate the Veteran's psychiatric disability in the context of the rating criteria and throughout the appeal period. Palczewski, supra. In light of this history and the evidence and arguments of record, the Board finds that all requisite duties to notify and assist have been complied with in this case and no further discussion is necessary, as compliance was addressed at length in the Board's previous decision and the findings contained therein with respect to that issue were not disturbed by the Court's order granting the parties' JMR. II. Disability Rating The Veteran's service-connected psychiatric disorder, currently characterized as PTSD with anxiety reaction, has been evaluated as 50 percent disabling since July 25, 2001, under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. The Veteran asserts that a higher rating is warranted, to include entitlement to a separate rating for his anxiety reaction. As noted in the introduction, the matter was recently remanded via the Court's granting of the parties' JMR. The basis for the Joint Motion included the Board's failure to address the Veteran's contention that VA had unlawfully severed his protected rating for his service-connected anxiety disorder. By way of background, the Veteran was granted service connection for anxiety reaction in October 1981, rated as 10 percent disabling under 38 C.F.R. § 4.130, DC 9400, effective from July 1, 1981. In August 1999, the Veteran requested to "reopen" his claim for PTSD, asserting that his service-connected disability had increased in severity. In a February 2000 decision, the RO continued that Veteran's 10 percent rating for his service-connected anxiety reaction and denied service connection for PTSD. In July 2001, the Veteran requested a "medical reassessment" of his service-connected anxiety disorder. VA treatment records dated thereafter included a diagnosis of PTSD, major depression, recurrent, generalized anxiety condition. A VA examination was conducted in July 2002, during which the Veteran revealed a previously undisclosed experience during service when he nearly drowned while in Vietnam. The examiner diagnosed PTSD, delayed, chronic, and general anxiety disorder. It was noted that the Veteran had recently had a bout of pulmonary infections, which the examiner indicated had caused a reemergence of the Veteran's depressive symptomatology and anxiety and PTSD symptoms. In a September 2002 rating decision, the Veteran was awarded service connection for PTSD, and a 30 percent rating was assigned under DC 9411 for PTSD with the anxiety reaction, effective from July 25, 2001. The rating decision also indicated that a rating for anxiety reaction alone under DC 9400 was no longer warranted as of July 25, 2001. The essence of the Veteran's argument is that his PTSD and anxiety reaction are two separate disabilities and that by assigning a single disability rating for PTSD with anxiety reaction under DC 9411, the RO improperly severed his protected rating under DC 9400 for his service-connected anxiety reaction. At the outset, the Board acknowledges that both service connection and a 10 percent rating for a psychiatric disability, however characterized, became "protected" as of July 1, 2001, and service connection will not terminated, nor will an evaluation of less than 10 percent be assigned. See 38 C.F.R. § 3.951(b) (2012) ("A disability which has been continuously rated at or above any evaluation of disability for 20 or more years for [VA] compensation purposes . . . will not be reduced to less than such evaluation except upon a showing that such rating was based on fraud. The 20-year period will be computed from the effective date of the evaluation to the effective date of reduction of evaluation."); see also 38 U.S.C.A. § 1159 (West 2002); 38 C.F.R. § 3.957 (2012) (The law provides that once service connection has been in force for a disability for ten or more years, service connection for that disability may not be severed unless it is shown that the original grant was based on fraud or that the veteran did not have the requisite service or character of discharge from service.) As to the Veteran's specific argument, the Board is also aware that in Murray v. Shinseki, the Court interpreted the protection afforded by § 3.951 as prohibiting VA from changing the applicable DC under which a veteran is rated for a particular disability, if rated for 20 years or more, even if that change did not result in a decreased overall rating to the veteran, and even if the symptoms for which the veteran was originally compensated no longer existed. 24 Vet. App. 420, 427 (2011). In Murray, the Veteran had been service connected for residuals of a left knee injury, evaluated as 10 percent disabling for more than 20 years under 38 C.F.R. § 4.71a, DC 5257, pertaining to recurrent subluxation or lateral instability. Thereafter, the Veteran claimed service connection for left knee arthritis and the RO subsequently reclassified his disability as residuals of a left knee injury with arthritis and assigned a 10 percent rating under 38 C.F.R. § 4.71a, DCs 5260 and 5261, pertaining to limitation of flexion and extension. The RO stated that to award separate ratings for arthritis and residuals of a left knee injury would violate 38 C.F.R. § 4.14's prohibition against pyramiding. Id. at 424. Ultimately, the Court concluded that the Veteran's protected disability rating under DC 5257 had effectively been reduced to zero percent and that he had been assigned a new, separate 10 percent disability rating. The Court found that the reduction from 10 to 0 percent under DC 5257 "violated the provisions of 38 C.F.R. § 3.951(b) that prohibit the reduction of a disability evaluation that has been continuous for 20 or more years." Id. The Board finds the instant case to be distinguishable from Murray because RO's action of recharacterizing the Veteran's psychiatric disability as PTSD with anxiety reaction did not in any way sever the award of service connection for anxiety reaction or reduce the disability rating assigned thereto. Rather, the RO increased the Veteran's disability rating to 30 percent based on the increase in severity of the Veteran's psychiatric symptoms and their effect on his social and occupational functioning. The change in diagnostic code simply reflected the additional diagnosis of PTSD rather than a reduction in rating for the Veteran's anxiety reaction. 38 C.F.R. § 4.125(b) (2012) ("If the diagnosis of a mental disorder is changed, the rating agency shall determine whether the new diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition."). Indeed, regardless of whether the Veteran's psychiatric disability is rated under DC 9400 or 9411, the rating criteria used to rate psychiatric disabilities are the same. That is, psychiatric disabilities such as these are rated under the General Rating Formula for Mental Disorders. See 38 C.F.R. 4.130. Notably, 38 C.F.R. § 4.14 prohibits "pyramiding," or the issuance of separate evaluations, for two or more disabilities with duplicative or overlapping symptoms. 38 C.F.R. § 4.14 (2012). As discussed in Amberman v. Shinseki, in the context of rating mental disorders, the focus should not be on the cause of the disorder, but rather on the manifestations of the disorder. 570 F.3d. 1377, 1381 (Fed. Cir. 2009). Thus, although it is possible for separate mental disorders to be manifested by different symptoms such that separate ratings would be warranted, "two defined diagnoses constitute the same disability for purposes of section 4.14 if they have overlapping symptomatology." Id. In the instant case, the Veteran has not presented, nor does the record contain, evidence that distinguishes manifestations of the service-connected anxiety disorder from the manifestations of the service-connected PTSD. Without such evidence and distinctive rating criteria, the Board cannot conclude that the Veteran is entitled to a separate rating for his anxiety disorder, such that the assignment of a singular rating under the criteria applicable to rating mental disorders, which rating clearly contemplates the effect of the Veteran's anxiety disorder on his functional capacity, constituted the impermissible reduction of the Veteran's protected rating for his anxiety disorder to zero percent or resulted in a severance of service connection for that disability. Notably, at the time that the Veteran was awarded service connection for anxiety reaction, his symptoms were anxiety, decreased libido, increased jumpiness, and some sleep disturbance. On examination in July 2002, the Veteran's symptoms were noted to be decreased libido, heightened startle response, moodiness, depression, sleep disturbances, difficulty concentrating, and anxiety. Although both PTSD and generalized anxiety disorder were diagnosed, there is no indication from that examination report that certain symptoms were attributable to only one mental disorder. Subsequent VA examinations and treatment records, as well as the Veteran's private treatment records, similarly fail to identify different manifestations of the Veteran's service-connected PTSD and anxiety reaction. Thus, because the evidence reveals that the Veteran's PTSD and anxiety reaction are manifested by overlapping symptomatology, they constitute a singular disability for the purposes of assigning a disability rating, see Amberman, supra; 38 C.F.R. § 4.14, and the Veteran's protected rating was actually increased to 30 percent. Accordingly, there is no basis upon which to conclude that the Veteran's protected 10 percent rating for his anxiety reaction was improperly severed when the RO increased that disability to 30 percent under DC 9411 (which the Board subsequently increased to 50 percent) due to the level of symptoms caused by his anxiety reaction with PTSD. Having determined that the Veteran's protected rating for his anxiety disorder has not been improperly severed, the Board turns to the question of whether the Veteran is entitled to a rating in excess of 50 percent for his psychiatric disability at any point since July 25, 2001. Under the general criteria for rating mental disorders, a 50 percent rating is assigned when 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-term 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. 38 C.F.R. 4.130, DCs 9201-9440. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting 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. Lastly, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability 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. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2012). The Board has considered the evidence of record, but finds that it does not support the assignment of a 70 or 100 percent rating at any point during the applicable time period. Evidence relevant to this determination shows that in May 2002 the Veteran presented to a VA community based outpatient clinic (CBOC) for treatment related to his PTSD. He reported an increase in his symptoms, which included difficulty sleeping, an inability to relax, feelings of uneasiness in crowded places, a severe startle reaction, and memory problems. He indicated that he was previously treated at a Vet Center in 1998, but had not received treatment since that time. Follow-up mental health treatment notes indicate that the Veteran was experiencing problems with energy, appetite, memory, and concentration. He reported a past history of suicidal thoughts in 1994, but indicated no thoughts of suicide since that time. It was noted that the Veteran had been married for 43 years, had three children, and had been retired since March 2000. Mental status examination revealed that the Veteran was tense, articulate, and tired looking. His affect was dull and mood depressed. A diagnosis of PTSD, major depression, and generalized anxiety condition was recorded and a GAF (Global Assessment of Functioning) score of 45 was assigned. A May 30, 2002, VA treatment record shows that the Veteran was neatly groomed, awake, alert, friendly, and cooperative. Some psychomotor agitation with frequent opening and closing of the hands and wiping of the palms was noted. His speech was normal and his stream of thought was goal oriented and logical in form. His affect was pleasant, mood subdued, insight good, and judgment intact. The clinician noted some symptoms of PTSD. The Veteran was afforded a VA examination in July 2002. He described symptoms of irritability, insomnia, difficulty concentrating while reading, praying, and watching television, decreased libido, moodiness, depression, anxiety, and tearfulness. The Veteran denied suicidal and homicidal ideation. The examiner noted that the Veteran was well groomed, oriented times three, cooperative, and able to perform serial sevens rapidly. There was no evidence of delusions or hallucinations and the Veteran's communication was straight forward, but tearful at times when he was describing the traumatic event. The examiner noted no dream experiences when asleep and stated that the Veteran had heightened physiologic arousal and was unable to form close social attachments. The examiner indicated that the Veteran's recent physical problems, to include hospitalization for pneumonia, pulmonary disease, and bronchitis, had caused a reemergence of his depressive symptomatology, stating that the stress of the physical illness and the Veteran's inability to work had brought his PTSD and anxiety symptoms to the foreground. A GAF score of 61 was assigned. An October 2002 VA treatment record noted that the Veteran had been seeing a private psychologist and that he reported significant improvement of his PTSD symptoms. In a January 2003 letter to his senator, the Veteran stated that his service-connected disabilities, to include his PTSD, prevented him from enjoying life like most normal people do. In June 2003, the Veteran returned to the VA CBOC on account of an upsurge in PTSD symptoms, especially anger. He indicated increased irritability at home and stated that his wife had left him due to his behavior. The Veteran expressed fear over the possibility of his marriage ending. The clinician noted that the Veteran was neatly groomed, awake, and alert. His speech was normal and his stream of thought was goal oriented. His affect was distraught and tearful, his insight fair, and his judgment intact. No bizarre or delusional ideation was expressed. The clinician assigned a GAF score of 40 and prescribed the Veteran with a medication to alleviate his symptoms. In a September 2003 statement, the Veteran's private physician, R.B., M.D., stated that the Veteran had been under his care for a variety of medical conditions, to include his PTSD. Dr. R.B. opined that the Veteran's PTSD prevented him from engaging in any type of employment due to his level of stress and depression. In February 2004, the Veteran reported anxiety attacks, panic attacks, and fits of rage. The Veteran was afforded another VA examination in March 2004, during which he reported an increase in the severity of his PTSD symptoms since his last VA examination. The Veteran reported that he was living with his wife of 45 years and had contact with his children and grandchildren. His leisure time was spent doing things around the house and volunteering at his church, doing such work as painting and renovations. He stated that he and his wife did not go out much on account of their finances and the fact that his wife was not very outgoing. He indicated that they held bible study classes in their home and had also gone to visit friends over the past weekend. Mental status examination revealed that the Veteran was dressed casually, but neatly. He spoke spontaneously and articulately and his responses were given in a goal-directed fashion. He showed a full range of affect and there were no signs of acute distress or any sad or depressed mood. He was fully oriented with no difficulties in short or long-term memory and there was no sign of any deficits in language function. Delusions, hallucinations, or current thoughts of suicide were not noted. The examiner reported that the Veteran had brought with him records from a private psychotherapist, from whom he had received nine therapy sessions between July 2002 and September 2003. The examiner stated that a review of those records showed that the private psychotherapist had assigned a GAF score of 68. Occupationally, the Veteran reported trying to work in June 2003, but stated that he was unable to do so because of his back pain. He also indicated that his inability to concentrate and attend to detail rendered him unable to perform home-based computer work. Although the Veteran claimed that he was unemployable, the examiner found no psychiatric reason why the Veteran could not be employed. The examiner noted that the Veteran performed physical labor around his home and at his church on a volunteer basis and indicated that the reasons why the Veteran did not socialize were economic. The examiner further noted that the Veteran had gone on a cruise vacation with his children and had indicated that he went out to restaurants while visiting his daughter. The examiner assigned a GAF score of 64 and expressed his opinion that the degree of social and occupational impairment due to the Veteran's PTSD was mild, specifically noting the GAF scores assigned by the private psychotherapist and previous VA examiner. Also in March 2004, Dr. R.B. provided a statement wherein he indicated that the Veteran had been a patient of his since April 2000, during which time his PTSD had increased in severity. Dr. R.B. noted that the Veteran had been prescribed several different anti-depressant medications, none of which alleviated his symptoms. Dr. R.B. also expressed his opinion that the Veteran was totally disabled and unable to engage in any type of employment due to his PTSD symptoms of anger, anxiety, memory loss, and inability to concentrate. In March 2005, the Veteran was awarded a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). The RO noted that the record contained contradictory evidence regarding employability, but determined that the residual effects of the Veteran's prostate cancer, when added to the effects of his other service-connected disabilities, resulted in unemployability. The Veteran also submitted a letter from private physician R.P., M.D., dated in September 2005, wherein it was indicated that the Veteran's PTSD symptoms continued at a level that precluded employment. Dr. R.P. based his opinion on the fact that the Veteran's symptoms were manageable in a homebound setting, but not the setting of continuous pressure and demands that would be present in a work environment. Dr. R.P. stated his belief that the Veteran's depressive and panic symptoms were the result of his PTSD and that the Veteran's PTSD symptoms caused clinically significant impairment in social and occupational functioning. Dr. R.P. also indicated that he had been treating the Veteran for over a year and stated that his current GAF score and his best GAF score in the past 12 months was 60-65. The accompanying private treatment records from Dr. R.P., dated from March 2004 to March 2006 note symptoms such as depression, crying spells, anger, forgetfulness, poor sleep, and decreased libido. His affect was described as blunted and his mood depressed. No risk of suicide or violence to others was noted. VA outpatient treatment records dated in March and April 2008 contain a positive PTSD screen. The Veteran indicated that he had experienced nightmares, avoidance, feelings of numbness and detachment from others, and a heightened startle response. In February 2009, the Veteran underwent another VA examination. The examiner stated that the claims folder was unavailable for review, but indicated that it would be reviewed when received. The Veteran reported that he had been married to his wife for 50 years, but that the relationship was strained due to her paranoid ideations and not his mental health problems. He described his relationship with his children as being very good. The Veteran stated that he had not engaged in any mental health treatment since moving from Colorado to Illinois in 2006, to include any psychopharmacological interventions. When relaying the details of the traumatic event, the Veteran did so without exhibiting any distressing emotion and was very animated in his story telling. The Veteran confirmed that he spent his leisure time doing projects around the house, volunteering at his church, watching television, and participating in bible study. He did state that he had reduced the amount of time spent volunteering on account of his physical problems. It was also suggested that it was not his PTSD, but rather his physical problems, combined with his wife's mental health problems, that impacted his ability to engage in hobbies and leisure pursuits. The Veteran was neatly dressed, alert, and fully oriented in all spheres. His speech was normal in rate, rhythm, and volume, and the content was logical and goal oriented. No motor anomalies attributable to psychiatric illness were noted. The Veteran described his mood and "almost a non-mood" the majority of the time, indicating that he was somewhat depressed and not as happy as he would like to be. The examiner described the Veteran's mood as euthymic and animated. His affect was mood congruent, full in range, and well-related. Hallucinations, delusions, and suicidal and homicidal ideation were denied. Cognitive and memory deficits were not reported, noted, or detected. The Veteran's insight was adequate and his judgment unimpaired. As to the Veteran's level of occupational and social impairment, the VA examiner agreed with the findings of the March 2004 examiner who stated that the Veteran's PTSD was mild and was not causing severe enough impairment to render him unemployable. The examiner noted that the Veteran had endorsed suffering from nightmares approximately once every one to two months, which were not always related to military service. In terms of avoidance phenomena and emotional numbing, the only symptom endorsed by the Veteran was markedly diminished participation in activities, which he had attributed to his physical disabilities and his wife's mental state. As for symptoms of increased arousal, the examiner noted difficulty staying asleep, irritability, and an exaggerated startle response. The examiner noted that the Veteran continued to be active in his church. He reported strong relationships with his children, grandchildren, and friends at church. The examiner found that the Veteran's occupational impairment was more due to his physical health than his PTSD. Results of psychiatric testing were suggestive of very mild PTSD. The examiner assigned a GAF score of 65 based on the fact that the Veteran's symptoms were mild in nature, that he had meaningful relationships, and that he engaged in activities. In March 2009, the VA examiner provided an addendum to the examination report based upon review of additional relevant records. Specifically, the VA examiner reviewed the statements submitted by Drs. R.B. and R.P., but noted no changes to his February 2009 examination report. The VA examiner found that the GAF score of 65 matched Dr. R.P.'s assessment of the Veteran. He further found that Dr. R.B.'s determination that the Veteran was totally disabled and unemployable was not supported by the Veteran's clinical interview, psychological testing, or daily behavior, nor did it match any other clinical assessment of record. In evaluating the severity of the Veteran's PTSD, the Board points out that "it is not the symptoms, but their effects, that determine the level of impairment." Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Thus, the Board must consider the actual level of occupational and social impairment caused by the Veteran's PTSD throughout the pendency of his claim. Furthermore, entitlement to a 70 percent rating "requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazques-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Based on the examination reports from the VA examiners in July 2002, March 2004, and February 2009, the VA outpatient treatment records, the private medical evidence, the recorded GAF scores, and the lay evidence of record, the Board finds that the Veteran's service-connected PTSD with anxiety reaction warrants no more than that currently assigned 50 percent disability rating. Notably, the Veteran has exhibited few symptoms of like kind to those associated with a 70 percent disability rating, save for difficulty adapting to stressful situations. He clearly does not have problems tantamount to suicidal ideation, obsessional rituals, near-continuous panic attacks or depression that affects his ability to function independently. There is no evidence of spatial disorientation, or neglect of personal appearance and hygiene. His insight is described as fair or good and his judgment intact or unimpaired. The evidence also fails to show that the Veteran is unable to maintain effective relationships. While some marital difficulty is suggested, the evidence indicates that any strain in that relationship is not due to the Veteran's mental health problems. Accordingly, because the evidence fails to show deficiencies in most areas due to symptoms equivalent in severity to those listed in the rating criteria for a 70 percent rating, the Board finds that a rating is excess of 50 percent is not warranted. In this regard, the Board notes that the GAF scores assigned during the relevant time period have ranged from 40 to 68. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed.1994) (DSM-IV). A GAF score of 61-70 is defined as: "Some moderate 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 generally functioning pretty well, has some meaningful interpersonal relationships." A GAF score of 51-60 is defined as: "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)." 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). A GAF score of 31-40 is assigned when there is "[s]ome 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; child frequently beats up younger children, is defiant at home, and is failing at school)." Id. While the GAF scores of 45 and 40, assigned in May 2002 and June 2003, respectively, are indicative of more serious impairment and symptomatology, the types of symptoms that would coincide with GAF scores of 40 and 45 were not noted in the treatment records. Indeed, in presenting to the VA CBOC in May 2002, the Veteran reported his symptoms to be difficulty sleeping, an inability to relax, feelings of uneasiness in crowded places, a severe startle reaction, decreased energy, difficulty concentrating, and memory problems. He denied any current thoughts of suicide and indicated that he had been married for 43 years. Further, in June 2003, the Veteran indicated increased irritability at home and stated that his wife had left him due to his behavior. The clinician noted that the Veteran was neatly groomed, awake, and alert. His speech was normal and his stream of thought was goal oriented. His affect was distraught and tearful, his insight fair, and his judgment intact. No bizarre or delusional ideation was expressed. A review of the VA treatment records dated in May 2002 fails to reveal evidence of the serious symptoms or serious impairment in social, occupational, or school functioning that would coincide with a GAF score of 45. While the Veteran reported marital problems in June 2003, there is no indication from the treatment record of some impairment in reality testing or communication or of major impairment in several areas. Further, as noted by the March 2004 VA examiner, contemporaneous records from a private psychotherapist show a GAF score of 68. Accordingly, the Board does not find the GAF scores of 40 and 45 to be consistent with the Veteran's symptomatology demonstrated at that time and therefore, the Board considers the scores unrepresentative of the level of disability experienced by the Veteran at that time. The Board notes that regardless of the GAF score assigned, that score must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a) (2012). The Board therefore finds that the actual symptoms reflected in the VA treatment records are more probative than the GAF scores recorded in May 2002 and June 2003 in terms of evidentiary value. Aside from the GAF scores of 40 and 45 recorded in the VA outpatient treatment records, the Veteran's assigned GAF scores during the relevant time period have ranged from 60 to 68. These GAF scores similarly do not reflect the more serious symptoms contemplated by a 70 percent disability rating. Further, the clinical evaluations of record fail to suggest that the assignment of GAF scores ranging from 60 to 68 are not reflective of the Veteran's actual level of impairment. The Board has considered whether the Veteran's PTSD has resulted in total social and occupational impairment, such that a 100 percent schedular evaluation is warranted, but finds that it has not. The Veteran had been married to his wife for more than 50 years, he maintains relationships with his children, has friends outside of his family, and his active in his church. Thus, regardless of the degree of occupational impairment, the evidence does not demonstrate that he is totally impaired. Accordingly, there is no basis upon which to assign a 100 percent rating See 38 C.F.R. § 4.130, DC 9411 (requiring "[t]otal occupational and social impairment" to establish entitlement to a 100 percent disability evaluation under the general rating formula for mental disorders) (emphasis added). The above determinations are based upon consideration of applicable rating provisions. The Board finds that the Veteran's disability level and symptomatology is adequately described by the rating criteria. Indeed, the Veteran's symptomatology, to include irritability, sleep issues, anger outbursts, depressed mood, diminished concentration, panic attacks, heightened startle response, and decreased concentration, anxiety and feelings of uneasiness, and forgetfulness are exactly the type of symptomatology contemplated by the rating criteria set forth under the general formula for rating mental disabilities. Without sufficient evidence reflecting that the Veteran's disability picture is so "exceptional or unusual," such that the available schedular evaluation for his service-connected psychiatric disability is somehow inadequate, referral for a determination of whether the Veteran's disability picture requires the assignment of an extra-schedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008); 38 C.F.R. § 3.321(b)(1) (2012). Lastly, the Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that the issue of entitlement to a total rating based upon individual unemployability due to service connected disability (TDIU) is part of an increased rating claim when that issue is raised by the record. The issue is raised whenever there is "cogent evidence of unemployability, regardless of whether [the claimant] states specifically that he is seeking TDIU benefits." Comer v. Peake, 552 F .3d 1362, 1366 (Fed.Cir.2009). Here, the Veteran was awarded a TDIU by way of a March 2005 RO decision, the award of which rating was made effective June 7, 2004. The Veteran filed a notice of disagreement as to the effective date of that award and a statement of the case addressing the issue was issued in October 2006. The evidence fails to reflect that the Veteran subsequently filed a VA Form 9 as to the issue of entitlement to an effective date prior to June 7, 2004, for the award of TDIU. Thus, the March 2005 RO decision became final. The Board finds that to address whether the Veteran was entitled to TDIU prior to June 7, 2004, as part of the increased rating issue currently before it would impermissibly undermine the finality of the March 2005 RO decision. Accordingly, the Board finds that it is prohibited from considering whether the Veteran was entitled to TDIU as part of the current claim. ORDER Entitlement to an evaluation for service-connected psychiatric disability in excess of 50 percent is denied. _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs