Citation Nr: 1324601 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 09-46 564A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for the period prior to December 5, 2011 for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial disability rating in excess of 70 percent from December 5, 2011 for PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD DeFrank, James INTRODUCTION The Veteran served on active duty from June 1969 to January 1972. These matters are before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision by the St. Louis, Missouri, Department of Veterans Affairs (VA) Regional Office (RO) which granted service connection for PTSD at a 30 percent disability evaluation, effective October 9, 2008. In a December 2011 rating decision, the RO granted a higher initial disability rating of 70 percent for PTSD effective December 5, 2011. As a higher evaluation for this disability is possible, the issue of entitlement to an initial rating in excess of 70 percent for PTSD since December 5, 2011 remains before the Board on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). The Board acknowledges that the Veteran's representative raised the issue of entitlement to a total disability rating based on individual unemployability (TDIU) in its March 2012 statement in lieu of a VA Form 646. Typically, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for entitlement to a TDIU will be considered to have been raised by the record as "part and parcel" of the underlying claim. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In this case, however, the RO explicitly initiated a claim for TDIU benefits as a result of its December 2011 rating decision that granted the Veteran a 70 percent rating for his service-connected PTSD. The RO sent the Veteran proper notice of how to substantiate such a claim in December 2011. The Veteran failed to respond to the RO's request for information. As a result, the RO denied the claim for a TDIU in January 2013. As the Veteran's intentions as to filing a claim for TDIU are unclear, given his lack of response to the request for information which would substantiate such a claim, and as the appeal period is still open for the January 2013 decision, the Board will not take jurisdiction of the TDIU claim at this time. FINDINGS OF FACT 1. Prior to December 5, 2011, the Veteran's PTSD symptoms are indicative of occupational and social impairment with no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. Since December 5, 2011, the Veteran's PTSD has not resulted in total occupational and social impairment due to 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; or memory loss for names of close relatives, own occupation or own name. CONCLUSIONS OF LAW 1. For the period prior to December 5, 2011, the criteria for entitlement to an initial disability evaluation in excess of 30 percent for PTSD have not been met or approximated. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411, 9434 (2012). 2. For the period since December 5, 2011, the criteria for entitlement to an initial disability evaluation in excess of 70 percent for PTSD have not been met or approximated. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411, 9434 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice 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. Notice should be sent prior to the appealed rating decision or, if sent after the rating decision, before a readjudication of the appeal. A Supplemental Statement of the Case, when issued following a notice letter, satisfies the due process and notification requirements for an adjudicative decision for these purposes. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided notice to the Veteran in an October 2008 letter, prior to the date of the issuance of the appealed February 2009 rating decision. The October 2008 letter explained what information and evidence was needed to substantiate the Veteran's claim as well as what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The letters also provided the appellant with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. Various written statements provided by the Veteran and by his representative are of record. Pertinent medical evidence associated with the claims file consists of service, private and VA treatment records, and the report of the Veteran's December 2008 and December 2011 VA examinations. Those examinations were conducted in conjunction with a review of the record and they address the Veteran's disability picture in relation to the applicable rating criteria. Thus, the Board finds that the reports are adequate on which to base a decision. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. To evaluate the severity of a particular disability, it is essential to consider its history. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1 and 4.2 (2011). Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. See 38 C.F.R. §§ 3.102, 4.3 (2011). In addition, where there is a question as to which of two disability evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2011). The Court has also held that in a claim of disagreement with the initial rating assigned following a grant of service connection separate ratings can be assigned for separate periods of time, based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2 In this case, the Veteran is currently assigned an initial 30 percent rating for PTSD, prior to December 5, 2011, and a 70 percent rating, from December 5, 2011, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board notes that psychiatric disabilities other than eating disorders are rated pursuant to the criteria for General Rating Formula. See 38 C.F.R. § 4.130. Under the general rating formula, a 30 percent rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversion normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires 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 affected 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. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Board notes that in accordance with the general rating formula, a maximum 100 percent rating is applicable if the manifestations of the service-connected psychiatric disorder result in total occupational and social impairment. Although the rating formula lists specific symptoms that are indicative of total impairment, the Court has held that the symptoms listed in the rating formula are only examples, and that evidence of those specific symptoms is not required to show that the veteran is totally disabled. In rating a mental disability, VA is required to consider all symptoms that affect her social and occupational functioning, and not limit consideration to those symptoms listed in the rating formula. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In other words, the primary consideration is whether the manifestations of the service-connected psychiatric disorder result in total social and occupational impairment, regardless of whether the Veteran demonstrates the symptoms listed in the rating formula. 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. One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). 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). Scores ranging from 41 to 50 reflect 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). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). While the rating schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. In addition to PTSD, for which service connection has been established, the record shows an additional diagnosis of depressive disorder not otherwise specified (NOS) and anxiety disorder. It is now well-settled that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability, in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The medical evidence in the instant case does not differentiate between the symptomatology associated with the Veteran's PTSD and that resulting from his nonservice-connected psychiatric disorders. Additionally, the December 2011 VA examiner noted that it was inferred that the Veteran was experiencing moderate depression secondary to PTSD trauma re-experiencing symptoms and the general effects of PTSD symptoms. Accordingly, for the purposes of this decision, the Board will attribute all of the Veteran's psychiatric symptoms to his service-connected PTSD. Factual Background and Analysis In August 2008, the Veteran presented to the VA Medical Center Mental Health Triage with complaints of nightmares and difficulty sleeping. He denied suicidal ideation but felt low occasionally. He had episodes where he almost hit his wife but he denied having done so. He was alert, oriented times three, appeared to be practicing good hygiene and was openly responsive to all inquiries. His mood was mostly euthymic with depressed mood at times. Speech and movement were within normal limits. He denied any audio or visual hallucinations or suicidal or homicidal ideations. He had decreased interest in activities "several days" over the past 2 weeks. He reported nightmares, extreme startle responses, intrusive thoughts and flashbacks. He had been married to his wife of 35 years and described their relationship as "excellent". He also had 3 children and described his relationship with them as "excellent". He felt that he had the support of his friends and family. The Axis I diagnosis was PTSD. A GAF score of 60 was recorded. In December 2008, the Veteran underwent a VA examination conducted by a private physician. The Veteran presented with complaints of sleeping only a few hours at a time, nightmares when he did sleep, and flashbacks. The severity of each of these symptoms was severe. It was noted that in September 1990 the Veteran was hospitalized for 3 days as he "pretty much shut down". He reported thoughts of suicide in 1990 but any plans for action were prevented by thoughts of his family. The Veteran also avoided people and feared loud noises. He experienced survivor's guilt and had nightmares, disturbed sleep, flashbacks and lowered motivation. His present PTSD symptoms were trauma re-experiencing, avoidance, numbing, heightened startle response, agitation, survivor guilt and demoralization. He experienced these symptoms several times monthly. He had no delusions or hallucinations. He did have inappropriate behavior as the particular information given during the interview was not consistent with the military record as he omitted major facts. He responded with ease with verbal questions but did not always address the designated topic. He had no plans or intent of suicidal thought. He was able to maintain minimum personal hygiene and other basic activities of daily living. He was oriented to person, place and time. He did have some memory loss and/or impairment as he sometimes could not recall parts of his military service or the names of his buddies. His symptoms did not interfere with his employment or social functioning. He did not have any obsessive or ritualistic behaviors that interfered with routine activities. He did have intermittent illogical or obscure speech patterns. He also had mild panic attacks. He had moderate depression or depressed mood as well as mild anxiety. He had moderate impaired impulse control as he was investigated for disciplining his son in a physically abusive manner. He had moderate sleep impairment. The diagnosis was PTSD and depressive disorder NOS. He did abuse alcohol when he initially got out of service. A GAF score of 75 was assigned. The physician concluded that the Veteran had PTSD signs and symptoms that were transient or mild, which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. An August 2009 VA treatment note reported that the Veteran presented with adequate grooming and hygiene. He demonstrated no abnormal psychomotor activity and was cooperative, friendly and attentive. His mood was euthymic and his affect was normal in range. Speech was normal rate and volume and was spontaneous in nature. He denied hallucinations or delusions. His thought process was goal directed and without delusions, paranoia, obsessions or compulsions. He denied suicidal or homicidal ideations or intent. He was alert and oriented to person, place and time. His memory was intact for both recent and long term. He demonstrated adequate insight and judgment and appeared to be a truthful reporter. The diagnosis was PTSD. A GAF score of 60 was recorded. A September 2009 VA treatment note again assigned a GAF score of 60. A March 2010 VA mental health treatment note indicated that the Veteran reported a depressed mood for the past 3 weeks that was triggered from reminders of Vietnam. The diagnosis was chronic PTSD and anxiety disorder. A GAF score of 58 was assigned. A March 2011 VA treatment note reported that the Veteran was alert to person, place, time and situation. His memory, judgment, insight and concentration were unimpaired. There were no signs or symptoms of psychosis. A GAF score of 65 was assigned. The Veteran underwent a VA examination in December 2011. The examiner noted that the Veteran had persistent re-experiencing of intrusive war trauma on a daily basis. These memories were "somewhat" manageable and required "quite a bit of effort" to dismiss. Their effects may last several hours and the associated distress is reported to be moderate. His house was located on a flight path between a fort and an Air Force Base and once or twice a week the sounds of the aircrafts triggered partially disassociative flashbacks. Sometimes he also experienced fully disassociative flashbacks during which he either felt that he was in Vietnam or that something that occurred in Vietnam was reoccurring. This was associated with "quite a bit" of distress and adversely impacted his ongoing activity. Several days a week he experienced distress ranging from moderate to "quite a bit" that was reactive to trauma reminders. This caused some activity disruption which would last up to an hour. Several days a week the reactions included psychophysiological arousal symptoms. Overall the frequency of these re-experiencing symptoms was fairly high and the intensity was severe for unwanted memories and moderate for the symptoms reactive to trauma reminders. The Veteran also experienced persistent avoidance of stimuli associated with trauma and/or numbing of general responsiveness. The avoidance symptoms had been occurring at a generally medium frequency with moderate intensity. Symptoms associated with "numbing" of general responsiveness were occurring at high frequency for reduced interest/participation in activities and interpersonal distancing, and at a medium frequency for emotional numbing and reduced sense of future. These "numbing" symptoms were of a generally moderate intensity but more severe for reduced interest and participation in activities. He also met the criterion for persistent experience of elevated arousal. The intensity was severe for irritability and hypervigilance and moderate for other PTSD arousal symptoms. Overall, the PTSD symptom severity was assessed to be moderately severe, with several significantly severe symptoms noted. There was also an indication of associated depression of moderate severity. He had depressed symptoms such as depressed mood, reduced interest and pleasure in things, reduced energy and fatigue, reduced self-esteem and restlessness. He noted that times he felt that he would be "better off dead" which especially occurred in the context of survivor guilt. It was inferred that he was experiencing moderate depression secondary to PTSD trauma re-experiencing symptoms and the general effects of PTSD symptoms. The examiner noted that the findings on this examination were significantly more severe than those noted at the last examination in December 2008. The Veteran was assigned a GAF score of 45. The examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran was currently married for 39 years and described the relationship as close and the level of trust in the relationship was fair. There was occasional arguing and conflict but they generally got along. He had 3 children and he was close with them as they "got along" well. He had an estranged brother who he did not keep in touch with. He maintained contact with his sister. Although they were close, he had difficulty demonstrating this closeness. The Veteran had a best friend who recently died. He also had some combat veteran friends. He participated in his American Legion chapter. He knew his neighbors and was neighborly with them but did not socialize with them. He was able to enjoy the shared activities with his spouse but would rather be alone at home. Most of his social activities were with his wife, children and 8 grandchildren. There was some retained capacity to enjoy social activities though he distanced himself from people he did not know fairly well. His basic social skills were good and he was generally able to be socially appropriate. Generally, he retained the capacity to enjoy and participate in some social activities and retained some capacity for closeness, trust and appropriate interaction with others. Moderate to nearing severe impairment in social functioning was indicated. The Veteran had worked in law enforcement for 32 years and retired in 2005. When working, he had no pattern of being late for duty, had moderate problems with work efficiency and at times was perceived to be insubordinate and disrespectful as he had frequent conflict with the Police Chief. Under increased levels of stress, his ability to concentrate would deteriorate. Examples of PTSD symptoms occurring at work included irritability and angry outburst, low energy and excessive fatigue (related to poor sleep), intrusive trauma memories, emotional reactivity to reminders of war trauma experiences, panic attacks and occasional flashbacks. In general, the occupational impairment attributed to PTSD was and would be serious but not total/major. The Veteran was competent of managing his financial affairs. He had impaired judgment as reflected in poor frustration tolerance with impulsive anger dyscontrol that sometimes caused regrettable consequences. His impulse control was episodically compromised but this was neither unprovoked nor violent in a physical sense. He also had reduced libido. His symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment mild memory loss, circumstantial, circumlocutory or stereotyped speech, impaired judgment, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, suicidal ideation and obsessional rituals which interfered with routine activities. On examination he was appropriately dressed and groomed. He was cooperative. He had motor restlessness throughout the examination. He was alert and grossly oriented to person, time, place and situation. His speech was spontaneous, circumstantial, pressured speech. His mood was anxious and depressed with irritability. His affect was mood congruent and reactive to trauma reminders. His insight was fair. His judgment was poor for impulsive behavior when frustrated. He complained of an inefficient short term memory. His concentration was inefficient. He had intact reality contact with no delusions or persistent hallucinations. He was overly circumstantial but there was no blocking or derailment of his flow of thought. He had occasional passive suicidal ideation, ruminative, with some guilty preoccupation and generally depressogenic thinking. He denied self lethality. He had nightly initial insomnia with 30 minutes of sleep latency and occasional trauma dreams. A December 2012 VA psychiatry attending note reported that the Veteran was despondent after the Presidential election and had a week of suicidal thoughts. He was not suicidal now. He was alert and oriented to time, place, person and situation. His speech was fluent, quiet and soft. His mood was depressed and irritable. His insight and judgment were good and his memory and concentration were unimpaired. He had no signs of psychosis. He denied suicidal or homicidal ideation, plan or intent. A GAF score of 50 was assigned. Regarding the period prior to December 5, 2011, after considering the totality of the evidence of record, the Board finds that the criteria for an initial evaluation in excess of 30 percent have not been met. The pertinent medical evidence collectively reflects that the Veteran's PTSD was primarily characterized by disturbed sleep, flashbacks, lowered motivation, trauma re-experiencing, avoidance, numbing, heightened startle response, agitation, survivor guilt and demoralization. The Board finds that these symptoms more nearly approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the level of impairment contemplated in the initial 30 percent disability rating for the period prior to December 5, 2011. The medical evidence does not show the Veteran to have flattened affect; panic attacks more than once a week; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; or other symptoms that are characteristic of the next higher, 50 percent rating. Rather, a March 2011 VA treatment note reported that the Veteran's memory, judgment, insight and concentration were unimpaired. Additionally, while the December 2008 VA examiner noted that the Veteran had intermittent illogical or obscure speech patterns and mild panic attacks, the examiner also specifically found that the Veteran had PTSD signs and symptoms that were transient or mild, which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. This description actually corresponds squarely with the schedular requirements for the assignment of a 30 percent disability rating. The Board notes that the GAF scores from this period range from 58 to 75. While the GAF scores of 58 and 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), the Board again notes that the Veteran's overall symptoms during this time period more nearly approximate the initial 30 percent disability rating. He has occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Additionally, the Board notes that GAF scores are only one indication of the severity of a given service-connected mental disorder. 38 C.F.R. § 4.130, Diagnostic Code 9411; see also Carpenter, supra. The aforementioned discussion makes clear that for the period prior to December 5, 2011, the Veteran's PTSD symptomatology has resulted in a disability picture that approximates no more than the level of occupational and social impairment contemplated in the assigned 30 percent rating under the applicable rating criteria. Regarding the period since December 5, 2011, the Board finds that a disability rating in excess of 70 percent is not warranted for any period of the claim. As noted above, the maximum rating of 100 percent requires total occupational and social impairment. VA treatment records and the December 2011 VA examination show no gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, inability to maintain personal hygiene, disorientation to time or place, or memory loss for names of own relatives, own occupation, or own name. Additionally, the December 2011 VA examiner specifically determined that there was not total occupational and social impairment due to the Veteran's PTSD signs and symptoms. In fact, the VA examiner noted that overall, the PTSD symptom severity was assessed to be moderately severe, with several significantly severe symptoms noted. The examiner also specifically found that the Veteran had occupational and social impairment with reduced reliability and productivity which actually corresponds squarely with the schedular requirements for the assignment of a 50 percent disability rating, rather than the current 70 percent disability rating for this period. Indeed, at no point did the December 2011 VA examiner or any other examiner or treating physician find that the Veteran's PTSD causes total occupational and social impairment, as is required for the assignment of a 100 percent rating. VA treatment reports also noted that while the Veteran had periods of suicidal thought, he had no current homicidal or suicidal thoughts or intentions, and he was oriented to person, place and time. The Board notes that the Veteran was assigned GAF score of 45 on VA examination in December 2011 which is indicative of 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). His current 70 percent rating, however, contemplates such serious symptoms. This is not evidence of total occupational and social impairment. Accordingly, in this case, the overall evidence of record on does not reflect that the Veteran's symptomatology was so severe as to merit a 100 percent evaluation. Thus, for all the foregoing reasons, the Board finds that since December 5, 2011, an initial rating in excess of 70 percent for PTSD is not warranted. Extraschedular Consideration The Board must still consider whether the Veteran is entitled to an extra-schedular rating under the provisions of 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the Board finds that the disability picture presented by the Veteran's PTSD disability is appropriately contemplated by the rating schedule. Indeed, higher evaluations are available, but the criteria for such evaluations have not been met. Therefore, referral for consideration of an extraschedular evaluation is not warranted here. Thun. ORDER Entitlement to an initial disability rating in excess of 30 percent for the period prior to December 5, 2011 for PTSD is denied. Entitlement to an initial disability rating in excess of 70 percent from December 5, 2011 for PTSD is denied. ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs