Citation Nr: 1324598 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 10-04 332A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to a higher initial disability rating (evaluation) for service-connected posttraumatic stress disorder (PTSD), in excess of 50 percent from December 28, 2004 to June 17, 2008, and in excess of 70 percent from June 17, 2008. ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from November 2001 to December 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which granted service connection for PTSD with a 50 percent rating effective September 12, 2007. The Board has reviewed the Veteran's physical claims file, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. The Board notes that, in a December 2009 rating decision, an earlier effective date of December 28, 2004 was awarded for the grant of service connection for PTSD with a 50 percent rating. Also, in a November 2012 rating decision, the RO granted a 70 percent rating for PTSD for the period from June 17, 2008. In consideration thereof, the Board will rate the PTSD with consideration of the entire rating period (i.e., beginning from the day after service separation, December 28, 2004), as well as the staged rating. During the course of the appeal, the Veteran was initially represented by the veterans service organization, Missouri Veterans Commission, and later represented by an attorney; however, in April 2013, the attorney submitted a motion to withdraw from VA representation, and the Board found that good cause for withdrawal had been shown. The Board thereafter advised the Veteran that the attorney had withdrawn representation and notified him of other options for representation. The Veteran did not respond to the letter; therefore, he is currently self-represented (pro se) in this matter. The Board has considered whether the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was reasonably raised by the record in this case. Rice v. Shinseki, 22 Vet. App. 447 (2009). In a November 2012 Decision Review Officer (DRO) decision, the Veteran was awarded a TDIU; therefore, because the benefit has already been granted, the Board finds that the issue of entitlement to a TDIU is not reasonably raised and is not part of the initial rating appeal. See November 2012 DRO decision. FINDINGS OF FACT 1. For the period from December 28, 2004 and prior to June 17, 2008, the Veteran's PTSD was manifested by sleep disturbance, irritability and infrequent episodes of assault, feelings of detachment from family, anxiety and panic-like symptoms, flat affect, and social avoidance but generally getting along well with family and co-workers. 2. From June 17, 2008, the Veteran's PTSD is manifested by loss of concentration during conversations, anxiety and frequent panic attacks, depressive symptoms, sleep disturbance, irritability, poor impulse control, hypervigilance, isolative behavior, and difficulty with maintaining work and social relationships. CONCLUSIONS OF LAW 1. The criteria for an initial disability evaluation in excess of 50 percent for service-connected PTSD have not been met or approximated for the rating period prior to June 17, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The criteria for an initial disability evaluation in excess of 70 percent for service-connected PTSD have not been met or approximated for the rating period from June 17, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.126, 4.130, DC 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). 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). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran is challenging the initial disability ratings assigned following the grant of service connection for PTSD in the July 2008 rating decision. The U.S. Court of Appeals for Veterans Claims (Court) has held that, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has in fact been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Furthermore, under 38 C.F.R. § 3.159(b)(3)(i), there is no duty to provide the Veteran with VCAA notice upon receipt of a Notice of Disagreement, such as in this case. For these reasons, the Board finds that no further notice, beyond that afforded in the context of the claim for service connection, is needed under the VCAA. Regarding VA's duty to assist in claims development, the RO afforded the Veteran with VA medical examinations in connection with the initial rating claim in June 2008 and September 2012. The VA medical examination reports include all relevant findings and medical opinions needed to evaluate fairly the Veteran's appeal. The VA medical examiners took a thorough history of the disability from the Veteran, including history of onset, diagnosis, report of symptomatology, other limitations, and treatment. The VA medical examiners had adequate facts and data regarding the history and condition of the disabilities. See VAOPGCPREC 20-95 (interpreting that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); see also Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). The VA medical examiners also considered the Veteran's subjective complaints as it related to current symptomatology and its effects on his daily life and performed a thorough mental evaluation of the Veteran. There has been no allegation or indication that there has been a material change in condition of the Veteran's disabilities since the last VA medical examination. For these reasons, the Board finds that the VA medical examination reports are adequate for rating purposes, and there is no need for further medical examination. Also, the Veteran's complete service treatment records and post-service treatment records adequately identified as relevant to the appeal have been obtained, or otherwise submitted, and are associated with the record. The additional treatment records pertinent to the appeal found in the Virtual VA folder were considered by the RO in the first instance. See October 2012 Supplemental Statement of the Case. The Veteran has not made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal, and no further development is required to comply with the duty to assist in developing the facts pertinent to the appeal. In view of the foregoing, the Board will proceed with appellate review. Disability Rating Criteria It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). The Board has thoroughly reviewed all the evidence in this case. The analysis below focuses on the most relevant evidence and on what this evidence shows, or fails to show, on the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. Where there is a question as to which of two evaluations shall be applied, 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. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In a claim for a higher original rating after an initial award of service connection, all the evidence submitted in support of a veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. The Veteran's PTSD is rated at 50 percent prior to June 17, 2008 and is rated at 70 percent from June 17, 2008 under the criteria found at 38 C.F.R § 4.130, DC 9411. Psychiatric disabilities are evaluated under the General Rating Formula for Mental Disorders. Upon review, the Board finds that no other diagnostic code or rating schedule would be appropriate in the evaluation of the Veteran's psychiatric disability. Under the General Rating Formula for Mental Disorders, a 50 percent rating is prescribed when there is evidence of 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. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 70 percent rating is provided when there is evidence that the psychiatric disability more closely approximates 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 worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires evidence of 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; and memory loss for names of close relatives, own occupation, or own name. Id. The Global Assessment of Functioning (GAF) scale reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the Diagnostic and Statistical Manual of Mental Disorders at 32 (4th ed. 1994)). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect 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 from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 11 to 20 reflect some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). DSM-IV at 46-47. When evaluating 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 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. When evaluating the level of disability 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. With regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. The use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list and are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) determined that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." Thus, the demonstrated symptomatology is the primary focus when deciding entitlement to a given disability rating and a veteran may be entitled to a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Id. Initial Rating for PTSD Rating Period from December 28, 2004 to June 17, 2008 After review of the lay and medical evidence pertinent to the portion of the rating period prior to June 17, 2008, the Board finds that the weight of the evidence is against finding that the disability picture associated with PTSD more closely approximates the schedular criteria for the next higher 70 percent disability rating. For the initial rating period from December 28, 2004 and prior to June 17, 2008, the PTSD was manifested by sleep disturbance, irritability, feelings of detachment from family, anxiety and panic-like symptoms, flat affect, and social avoidance but generally getting along well with family and co-workers. For this period, the PTSD does not demonstrate or more nearly approximate occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to PTSD symptoms. Regarding occupational impairment, the evidence weighs against finding that the Veteran's occupational impairment was so severe due to PTSD symptomatology to warrant the higher initial rating of 70 percent for the portion of the rating period prior to June 17, 2008. In December 2005, the Veteran reported that he worked full-time with his father's remodeling business, was satisfied with the job, and was able to function well on the job. Later, when seeking mental health treatment in January 2008, the Veteran reported that he had been working with a construction company for eight to nine months and was doing "ok" getting along with co-workers. Regarding social impairment, the evidence has demonstrated some difficulty establishing and maintaining effective relationships; however, the evidence does not show an inability to do so. When seeking mental health treatment in January 2008, the Veteran generally reported feeling detached from family but stated that his relationship with his parents was "great" and the relationship with his siblings was "ok." Throughout this portion of the rating period, the Veteran also maintained a relationship with his current wife, albeit with some volatility as explained below. This evidence further weighs against the assignment of a 70 percent disability rating. The degree of social impairment demonstrated is already contemplated in the 50 percent disability rating. The evidence shows that the Veteran engaged in obsessional rituals; however, such are not shown to have interfered with routine activities. In January 2008, the Veteran reported that he frequently checked doors and windows at night and throughout the day. In January 2008, he reported being charged with third degree assault after fighting with his girlfriend, and having had a physical altercation with another man. Aside from this one episode, the evidence does not show deficiency in impulse control with periods of violence. While the Veteran reported in August 2005 that he had choked his girlfriend, this was not indicative of a violent episode or impaired impulse control, as the Veteran did this during his sleep. Such evidence of twitching and uncontrollable actions during sleep is like or similar to chronic sleep impairment, as the Veteran at that time is unaware of the object of his actions. The evidence also does not show that the Veteran had suicidal ideation or demonstrated speech was intermittently illogical, obscure, or irrelevant. Review of the relevant VA treatment records shows that the Veteran consistently denied having suicidal ideation and has routinely demonstrated normal speech during this portion of the rating period. The evidence also does not show spatial disorientation or neglect of personal appearance and hygiene. The VA treatment records contain no evidence of spatial disorientation, and the Veteran demonstrated good hygiene and a neat appearance. Although the evidence demonstrated symptoms of anxiety and panic-like symptoms, there is no indication that the symptoms prevented him from functioning independently, appropriately, and effectively. Also, the evidence does not show that the Veteran had significant difficulty in adapting to stressful circumstances, to include work and work-like settings. As stated above, the Veteran was able to maintain a full-time job working in his father's remodeling business and work full-time for a construction company during this portion of the rating period. In December 2005, the Veteran reported that he was able to function on the job well. This evidence weighs against finding that the Veteran was unable to function independently, appropriately, and effectively or that he had significant difficulty in adapting to stressful circumstances, to include work and work-like settings. The Board further notes that the Veteran once reported in September 2005 that he occasionally hears people calling his name when no one is there; however, the Veteran routinely denied having hallucinations or delusions associated with PTSD. The Board observes that VA mental health providers assigned GAF scores ranging from 51 to 65, which reflects mild to moderate symptoms or mild to moderate difficulty in social, occupational, or school functioning. Upon review of the relevant VA treatment records, the Board notes that the Veteran's PTSD is manifested by sleep disturbance, irritability, feelings of detachment from family, anxiety and panic-like symptoms, flat affect, and social avoidance, but generally getting along well with family and co-workers. After considering the evidence of functional impairment and symptoms associated with PTSD, the Board finds that the GAF scores assigned by treating VA mental health professionals are adequately contemplated by the criteria for the current 50 percent disability rating, and no higher initial rating is warranted for this portion of the rating period. Rating Period from June 17, 2008 After review of the lay and medical evidence pertinent to the portion of the rating period from June 17, 2008, the Board finds that the weight of the evidence is against finding that the disability picture associated with PTSD more closely approximates the schedular criteria for the maximum disability rating of 100 percent for this period. The evidence shows that, for the period from June 17, 2008, PTSD has manifested loss of concentration during conversations, anxiety and frequent panic attacks, depressive symptoms, sleep disturbance, irritability, hypervigilance, isolative behavior, and difficulty with maintaining work and social relationships. The evidence does not show that the Veteran had total occupational and social impairment due to PTSD symptomatology for rating period. Regarding occupational impairment, the evidence shows that the Veteran's PTSD symptoms have interfered with work functioning; however, the Veteran was able to maintain full-time employment from June 2008 until approximately April 2009, when his employment ended primarily due to physical disability. At the June 2008 VA PTSD examination, the Veteran reported that he experienced poor memory, depressive symptoms, frequent anxiety with four to five panic attacks during the day, problems with anger and assertions of assaultive behavior, and sleep disturbance, and engaged in isolative behavior. However, notwithstanding the characterizations of assaultive behavior and isolative behavior, the Veteran was working full time as a team leader in the flooring department of a home improvement store and had been working there for two weeks. The fact that the Veteran had full-time employment despite PTSD symptoms weighs against finding that the Veteran's PTSD symptomatology caused total occupational impairment. At the more recent September 2012 VA PTSD examination, the Veteran was noted to have a low tolerance for stress, isolative behaviors, irritability, and anger outbursts that had interfered with work functioning; however, after considering the Veteran's past and present psychiatric complaints and treatment and performing a thorough evaluation of the Veteran, the VA PTSD examiner opined that the Veteran's occupational and social impairment due to PTSD was best summarized as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, which is consistent with the criteria for the current 70 percent schedular rating. Importantly, the VA PTSD examiner had the option, but did not choose, to describe the Veteran's occupational and social impairment due to PTSD as a "total" occupational and social impairment. This evidence also weighs against finding that an increased schedular rating of 100 percent is warranted. The Board recognizes that the Veteran told a treating VA mental health provider in May 2009 that he had recently quit the job at the home improvement store due to a "falling out" with supervisors when he was not given his old full time job back; however, in September 2009, he told the same VA treating mental health provider that he did not quit the job as he had previously reported but was fired due to having to miss work to come to VA appointments. He similarly reported at the September 2012 VA PTSD examination that he was fired due to having to miss work to attend VA appointments. In a December 2009 affidavit previously submitted in connection with a claim for total disability rating based on individual unemployability (TDIU), the Veteran wrote that he was "let go from [the store]" because of lost time due to back problems and VA appointments. He then stated that his PTSD symptoms of anger, irritability, and difficulty dealing with others interfered with his employment and that he had been unable to work due to the combined effect of his service-connected disabilities since April 2009. The Veteran did not indicate that symptoms of PTSD were the sole or primary reason for terminating his employment. Also, at the September 2012 VA PTSD examination, the Veteran reported that he had been unable to work since 2010 after fracturing his spine and clavicle in a car accident, and potential employers had expressed reluctance to hire him due to his neck problems. See also July 2009 VA psychiatry note (wherein the Veteran stated that his back kept him from working certain jobs). Although the Veteran indicated that he often had to leave the situation when customers challenged him during his time working at the store, he did not indicate that he was unable to work due to PTSD symptomatology. Therefore, the Veteran's statements provide further evidence against finding that PTSD has resulted in total occupational impairment. Regarding social impairment, the evidence shows that the Veteran has periodic conflict with his wife and has frequently engaged in assaultive behaviors with others but is able to maintain social relationships to some degree for the portion of the rating period from June 17, 2008. For example, at the June 2008 VA PTSD examination, the Veteran reported that he had conflict with his family and argued fiercely with his wife; however, he also stated that he helped his wife with the kids, generally got along with his family pretty well, and had three friends that he saw on a regular basis. At the September 2012 VA PTSD examination, the Veteran reported marital conflict due to PTSD symptoms but remained married to his wife and reported that they had been together for nine years. He also reported that he was becoming increasingly secluded, avoided people, and did not go out to public places; however, he had one friend and would have his friend over or go over to the friend's house. VA treatment records show that the Veteran reported engaging in physically assaultive behavior with his father-in-law and a former friend in August 2009 and November 2009, respectively; however, the Veteran maintained a relationship with his wife and children and other family members to some degree, albeit strained. See, e.g., July 2009 VA psychiatry note and October 2012 VA treatment note. This evidence weighs against finding that the Veteran has total social impairment due solely to PTSD. The Board further notes that the evidence does not demonstrate other symptomatology contemplated in the criteria for the 100 percent schedular rating for the portion of the rating period from June 17, 2008, though no specific number of criteria need be met for a higher rating. The evidence does not show that the Veteran demonstrated gross impairment in thought processes or communication. The June 2008 VA PTSD examiner described the Veteran's thought process and thought content as unremarkable and described his speech as unremarkable, spontaneous, and clear. The September 2012 VA PTSD examiner similarly noted that the Veteran's thoughts were logical and goal-directed and the speech was within normal limits. Relevant VA treatment records include no contrary findings. Also, the evidence does not show that the Veteran has demonstrated intermittent inability to perform activities of daily living, to include maintenance of minimal personal hygiene, or demonstrated disorientation to time or place. Mental health professionals have routinely noted that the Veteran was well-groomed, alert and/or oriented. The Veteran has shown no evidence of persistent delusions. Although the June 2008 VA PTSD examiner noted that the Veteran had persistent auditory hallucinations, the June 2008 VA PTSD examiner provided no explanation for the finding. The Board notes that VA treatment records show no evidence of auditory hallucinations, and the September 2012 VA PTSD examiner noted that there was no evidence of psychosis. As it is likely that other VA mental health professionals would have noted the presence of auditory hallucinations, if they are persistent, during the course of treatment or evaluation for this portion of the rating period, the absence of any such finding by treating mental health providers and the fact that the Veteran showed no evidence of psychosis at the September 2012 VA PTSD examination is significant. For these reasons, the Board affords the VA treatment records and September 2012 VA PTSD examination report, which show no evidence of persistent hallucinations, more probative value than the June 2008 VA PTSD examination report. The Board finds that the weight of the evidence does not show that the Veteran has persistent auditory hallucinations during this portion of the rating period. Additionally, the evidence shows that the Veteran has some memory loss; however, the Veteran's memory problems are not of the level of severity contemplated by a 100 percent schedular rating. At the June 2008 VA PTSD examination, the Veteran told the June 2008 VA PTSD examiner that he had trouble remembering dates and names and rechecked tasks at work. However, the Veteran is not shown to have had memory loss for names of close relatives, his own occupation, or his own name at any time relevant to this portion of the rating period. The memory problems reported by the Veteran are contemplated in the schedular criteria for the lesser 30 percent rating (i.e., forgetting names and recent events) and 50 percent rating (i.e., forgetting to complete tasks); therefore, the Veteran's memory problems are considered in the current 70 percent rating, which subsumes the criteria associated with lesser schedular ratings. The evidence further shows some inappropriate behavior during this portion of the rating period; however, the Veteran does not exhibit persistent danger of hurting himself or others. At the June 2008 VA PTSD examination, the VA examiner noted that the Veteran's inappropriate behavior was manifested by fiercely arguing with his wife, throwing his wife over the coffee table during his sleep, avoiding public places because he gets mad and goes into "killing mode," and being nervous and shaky in public. Although the Veteran has frequently engaged in physically assaultive behavior, he has also demonstrated an ability to walk away from a confrontation and has never killed another person despite his reference to being in "killing mode." Also, after having repeatedly denied having thoughts of harming himself throughout this portion of the rating period, the Veteran told a VA mental health provider in October 2012 that he had suicidal thoughts; however, the Veteran stated that he had no plan and had not had a suicide attempt. Suicidal ideation, when there is not a persistent danger of harming oneself or others, is contemplated in the criteria for the current 70 percent rating. The Board observes that the September 2012 VA PTSD examiner assigned a GAF score of 20 when evaluating the Veteran, which reflects the VA examiner's belief that the Veteran demonstrated some danger of hurting himself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally failed to maintain minimal personal hygiene (e.g., smears feces) or had gross impairment in communication (e.g., largely incoherent or mute). The VA PTSD examiner explained that the GAF score was assigned primarily due to the presence of danger of hurting others because the Veteran had been in approximately twenty physical altercations in the last year and had recently been held in jail for assault. However, less than a month later, a VA mental health provider who evaluated the Veteran for recent suicidal thoughts assigned a GAF score of 51, which is reflective of moderate symptoms of PTSD or moderate difficulty in social and occupational functioning due to PTSD. Throughout this portion of the rating period, VA mental health professionals before and after the September 2012 VA PTSD examination have assigned GAF scores ranging from 45 to 60, which reflects moderate to serious symptoms of PTSD or moderate to serious impairment in social and occupational functioning due to PTSD. When weighing the evidence, the Board finds that the GAF scores assigned by treating VA mental health professionals before and after the September 2012 VA PTSD examination, as well as the GAF score of 45 assigned by the June 2008 VA PTSD examiner, are more consistent with the PTSD symptoms and overall disability picture shown by the evidence. After consideration of the foregoing, the Board finds that the level of occupational and social impairment due to PTSD symptoms is adequately compensated by the 70 schedular rating. From June 17, 2008, the Veteran's PTSD has been manifested by loss of concentration during conversations, anxiety and frequent panic attacks, depressive symptoms, sleep disturbance, irritability, poor impulse control with episodes of violence/assault, hypervigilance, isolative behavior, and difficulty with maintaining work and social relationships. The overall disability picture does not show total occupational and social impairment due to PTSD symptomatology; therefore, a higher initial rating of 100 percent is not warranted. In summary, the Board finds that the manifestations of the Veteran's PTSD do not meet or more nearly approximate the schedular criteria for a higher initial rating for either portion of the rating period. The Veteran's PTSD symptoms and functional (occupational and social) impairment are contemplated by the staged ratings for the respective periods. For these reasons, the Board finds that the weight of the evidence is against the assignment of a higher initial rating on a schedular basis for any period. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has further considered whether the initial rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that the schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. If those criteria are not inadequate, the analysis does not need to proceed any further. In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the currently assigned staged rating (i.e., 50 percent prior to June 17, 2008 and 70 percent from June 17, 2008). In this case, the schedular rating criteria contemplate the impairments and symptoms associated with the Veteran's PTSD. The symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of symptoms and clinical findings. Prior to June 17, 2008, the Veteran's PTSD is manifested by sleep disturbance, irritability, feelings of detachment from family, anxiety and panic-like symptoms, flat affect, and social avoidance but generally getting along well with family and co-workers. From June 17, 2008, the Veteran's PTSD was manifested by loss of concentration during conversations, anxiety and frequent panic attacks, depressive symptoms, sleep disturbance, irritability, hypervigilance, isolative behavior, and difficulty with maintaining work and social relationships. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Because the schedular rating criteria is adequate to rate the Veteran's PTSD disability, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER A higher initial disability rating for PTSD, in excess of 50 percent prior to June 17, 2008, and in excess of 70 percent from June 17, 2008, is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs