Citation Nr: 1324766 Decision Date: 08/05/13 Archive Date: 08/13/13 DOCKET NO. 10-00 424 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) from October 23, 2008, through April 16, 2011. 2. Entitlement to a staged initial rating in excess of 70 percent for PTSD from April 17, 2011. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD C. Hancock, Counsel INTRODUCTION The Veteran served on active duty from June 2000 to October 2008. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. There, the RO granted the Veteran's claim for service connection for posttraumatic stress disorder (PTSD) and assigned a 30 percent rating effective from October 23, 2008. The Veteran perfected an appeal of the initial rating assigned following the April 2009 grant of service connection for PTSD. Fenderson v. West, 12 Vet. App. 119, 126 (1999) (holding that, where a veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim for service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found). The RO later, in January 2012, increased the disability rating assigned to the Veteran's service-connected PTSD to 70 percent, effective April 27, 2011. On a claim for an increased rating, the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Since the grant of the 70 percent rating is not a full grant of the benefits sought on appeal, and since the Veteran did not withdraw his claim of entitlement to an increased rating, the matter remains before the Board for appellate review. The Veteran failed to report for a video conference hearing which was to have been conducted by a Veterans Law Judge in July 2013. Therefore, the Board will proceed as if the request for the recent July 2013 hearing had been withdrawn. 38 C.F.R. § 20.704(d). FINDINGS OF FACT 1. For the period from October 23, 2008, through December 6, 2009, the probative evidence shows that the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment most comparable to occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. From December 7, 2009, through April 26, 2011, the probative evidence shows that the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment most comparable to deficiencies in most areas, to include an inability to establish and maintain effective relationships. 3. From April 27, 2011, the Veteran's PTSD has been manifested by symptoms productive of occupational and social impairment most comparable to deficiencies in most areas, to include an inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. From October 23, 2008, through December 6, 2009, the criteria for an initial rating in excess of 30 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159 , 4.2, 4.7, 4.10, 4.130, Diagnostic Code (Code) 9411 (2012). 2. From December 7, 2009, through April 26, 2011, the criteria for the assignment of a 70 percent staged rating, but no higher, for the Veteran's PTSD were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.2, 4.7, 4.10, 4.130, Diagnostic Code (Code) 9411 (2012). 3. From April 27, 2011, the criteria for the assignment of a rating in excess of 70 percent rating for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.2, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties To Notify And Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his/her representative, if applicable, 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also 73 Fed. Reg. 23,353-56 (Apr. 30, 2008). Further, upon receipt of claim for service connection for a disability, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran is appealing the initial rating assignment as to his PTSD. No duty to notify arises from a notice of disagreement. 38 C.F.R. § 3.159(b)(3) (2012). Rather, the Veteran's appeal as to the initial rating assignment triggers VA's obligation to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. 38 U.S.C.A. §§ 5104 and 7105 (West 2002). In this case, the notice obligations set forth in §§ 5104 and 7105 were met when the RO issued a November 2009 Statement of the Case (SOC). The SOC provided citations to the pertinent regulations involved, a summary of the evidence considered, and notice of the decision and the reasons for the decision. 38 U.S.C.A. § 7105(d). Neither the Veteran nor his representative have argued that there was any deficiency with regard to the notice requirements. Accordingly, the Board concludes that, in this case, the RO met the notice obligations set forth in §§ 5104 and 7105 of the statute. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disability at issue. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). VA has also satisfied its duty to assist the Veteran in this case. The Veteran's service treatment records as well as all identified and available VA and private medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. This include VA medical records included within "Virtual VA" (an electronic data-based system). Neither the Veteran nor his representative has identified any outstanding medical records. In addition, the Veteran was afforded VA examinations with respect to the matter on appeal in January 2009 (with addendum opinion issued in July 2009), April 2011, and in May 2012. 38 C.F.R. §3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The examinations here are adequate, in that they included a comprehensive review of the Veteran's medical history (with the exception of the January 2009 examination; the addendum addressed this defect) and also included sufficient medical findings relating the applicable rating criteria. There is also no evidence indicating that there has been a material change in the severity of the Veteran's service-connected PTSD since he was last examined in May 2012. 38 C.F.R. § 3.327(a). Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the initial rating issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). Accordingly, the duty to assist the Veteran with the development of evidence pertinent to his claim has been satisfied. Factual Background The Veteran essentially contends that the severity of his PTSD symptoms warrant the assignment of an initial rating in excess of 30 percent for the period from October 23, 2008, to April 26, 2011, and a staged rating in excess of 70 percent from April 27, 2011. A November 2008 VA mental health outpatient record shows that the Veteran presented with increasing anger and irritability in the past few months. He complained of trouble sleeping, exaggerated startle response, and difficulty concentrating. He denied depressed mood, anhedonia, changes in appetite and body weight. He admitted thoughts of his own death, but not by suicide. Examination showed the Veteran to be cooperative, engageable, and hypervigilant. Speech was normal. Affect was full, yet sometimes angry; thought process was coherent and goal directed; he denied suicidal ideation, cognition was normal; concentration was intact; memory was intact; and insight and judgment were described as good. PTSD was diagnosed. A Global Assessment of Functioning (GAF) score of 58 was provided. A January 2009 VA initial evaluation for PTSD shows that the Veteran's electronic medical records were reviewed (though his claims folder was not). He was administered a clinical interview, including mental status examination. The Veteran expressed problems with anger, nightmares and flashbacks, and daily intrusive thoughts. He also complained of survivor's guilt. The Veteran complained of mild insomnia. The Veteran was noted to be seeking employment. He also complained of problems associated with long term memory. The Veteran was reported to be able to complete normal activities of daily living without significant impairment and was fully independent. He spent his days looking for work and playing with his children. On examination, the Veteran was casually dressed and well groomed. He was articulate. Social skills were good. His thought process was logical, coherent, and logical. He was alert and oriented times four. Affect was anxious. The Veteran's reasoning and judgment were described as fair. The Veteran did complain of trouble with concentration and short and long term memory. The report of a December 2008 VA neuropsychological report was noted to show that the Veteran's cognitive deficits were attributable to both psychiatric issues and his proximity to multiple gun blasts. The Board notes that the Veteran is service-connected for traumatic brain injury residuals, evaluated as 70 percent disabling. See August 2012 RO rating decision. The Veteran also complained of anxiety, panic attacks, and irritability coupled with rageful outbursts. He denied delusional thinking, as well as suicidal or homicidal ideation. The examiner commented that accessing occupational functioning was difficult since while the Veteran was not employed, this was due in part to economic factors. The examiner commented that the Veteran did show signs of moderate impact on social functioning, although he described a positive relationship with his wife and kids and his mother. The examiner found that the Veteran met the criteria for PTSD. A GAF score of 60 was provided. A January 2009 mental health attending note shows that chronic and severe PTSD was diagnosed. Mental status examination showed his speech as being intense, intact and articulate. His mood was described as "not too good," and affect was congruent. He denied suicidal and homicidal ideation or plan. Insight, judgment, and cognition were good. The RO granted service connection for PTSD in April 2009. A 30 percent rating, effective from October 23, 2008, was assigned. The Veteran was notified of this decision in April 2009, and supplied VA with a NOD in May 2009, initiating his appeal. The appeal was subsequently perfected in a timely manner. In July 2009, the examiner, who examined the Veteran in the course of the January 2009 VA examination, supplied an opinion only/addendum. He found that while the Veteran's psychiatric-based issues caused moderately negative occupational functioning, he opined that the Veteran was not unemployable from a "psychiatric perspective." A December 7, 2009, VA mental health attending note reveals that the Veteran reported his involvement in recent interpersonal incidents which caused him to experience increased PTSD symptoms. On examination he was casually dressed and cooperative. His speech was intact, intense, and articulate. His mood was described as "stressed." Affect was congruent. He denied audio visual hallucinations and was not suicidal or homicidal. Insight, judgment, and cognition were all intact. PTSD, described as chronic and severe, was diagnosed. A GAF score of 45 was provided. A February 2010 VA mental health telephone encounter note shows that the Veteran reported having a severe panic attack the day before. He added he was neither suicidal or homicidal, that he slept good, and had a poor appetite. PTSD was diagnosed, and a GAF score of 45 was provided. A March 2010 VA mental health attending note shows that the Veteran reported an increase in panic attacks over the past few months. Mental status examination showed normal speech, "stressed" mood, and congruent affect. The Veteran denied hallucinations and suicidal/homicidal ideation or plan. Insight, judgment, and cognition were all intact. PTSD was diagnosed, and a GAF score of 45 was provided. An October 2010 VA mental health attending note reveals that the Veteran reported continuing PTSD symptoms, including insomnia, anger, irritability, and anxiety. He reported improved symptoms with Lorazepam use. On examination he was casually dressed and cooperative. His speech was intact, and his mood was described as "stressed." Affect was congruent. He denied audio visual hallucinations and was not suicidal or homicidal. Insight, judgment, and cognition were all intact. PTSD, described as chronic and severe, was diagnosed. A GAF score of 45 was provided. The report of an April 27, 2011, VA PTSD examination shows that the Veteran was casually dressed and his affect was appropriate. Thought processes were clear, logical, linear, coherent, and goal directed. Examination showed that his speech to be within normal limits, and that while he was oriented to person, place and time he guessed at the date. The Veteran reported memory problems. He noted having homicidal ideation but no plan. The Veteran denied having panic attacks. Impaired impulse control was not observed. A history of delusions and hallucinations was reported by the Veteran. The Veteran reported sleeping for four hours, accompanied by nightmares. The Veteran was noted to have recurrent intrusive images or thoughts, persistent avoidance of triggers and numbing, and persistent symptoms of increased arousal. The examiner commented that the symptoms were chronic (more than three months in duration). The supplied diagnoses were PTSD and depression. A GAF score of 40 was provided. A recent GAF score of 45 from February 2011 was also noted. The examiner cited the wording in the DSM-IV (American Psychiatric Association : Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) which corresponds to a GAF finding of 31 to 40. The examiner added that the Veteran had not sought to attend school nor work since his last examination due to hypervigilence and discomfort with other people. It was also noted that the Veteran was mostly unable to drive; the reason was not clear. The Veteran reported having little interaction with his family, except for his brother. He noted having no rewarding social relationships. The examiner cited the symptoms represented in Diagnostic Code 9411 as being indicative of a 70 percent disability in describing the Veteran's symptoms. A November 2011 VA mental health attending note reveals that the Veteran reported an incident two weeks earlier, where a stranger drew his gun on him in his yard. He reported increased feelings of anxiousness and paranoia. On examination he was casually dressed and cooperative. His speech was intact, and his mood was described as "better." Affect was congruent. He denied audio visual hallucinations and was not suicidal or homicidal. Insight, judgment, and cognition were all intact. PTSD, described as chronic and severe, was diagnosed. A GAF score of 45 was provided. The RO, as part of a January 2012 rating decision, increased the disability rating assigned to the Veteran's service-connected PTSD from 30 to 70 percent, effective from April 27, 2011. The report of a May 2012 PTSD VA examination report shows that PTSD was diagnosed, and a GAF score of 40 was supplied. The examiner characterized the level of the Veteran's occupational and social impairment as being indicative of deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. He added the severity of the PTSD was be equivalent to that found in the course of the VA examination conducted on April 27, 2011 (see findings above). A June 2012 VA mental health attending note shows that the Veteran reported mostly staying indoors, limiting his interactions with others. On examination he was casually dressed and cooperative. His speech was intact, and his mood was described as "better." Affect was congruent. He denied audio visual hallucinations and was not suicidal or homicidal. Insight, judgment, and cognition were all intact. PTSD, described as chronic and severe, was diagnosed. A GAF score of 45 was provided. A September 2012 VA mental health attending note shows that his wife took him to the hospital after he had a "breakdown." He was not admitted. On examination he was casually dressed and cooperative. His speech was intact, and his mood was stressed and confused. Affect was congruent. He denied audio visual hallucinations and was not suicidal or homicidal. Insight, judgment, and cognition were all intact. PTSD, described as chronic and severe, was diagnosed. A GAF score of 45 was provided. Laws and Regulations Disability ratings are based upon the average impairment of earning capacity as determined by a Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. Id. An evaluation of the level of disability present also includes consideration of the Veteran's ability to engage in ordinary activities, including employment, and the effect of symptoms on the functional abilities. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. This appeal originates from a rating decision that granted service connection and assigned the initial rating. Accordingly, "staged" ratings may be assigned, if warranted by the evidence. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under 38 C.F.R. § 4.130, Diagnostic Code (Code) 9411, a 30 percent rating is warranted for PTSD, for 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 conversation 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 is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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. A 100 percent evaluation for PTSD 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 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. Diagnostic Code 9411. Disability ratings are assigned according to the manifestation of particular symptoms, as listed in the rating formula. The list of symptoms in the rating formula above is not intended to constitute an exhaustive list, but rather shows examples of the types and degrees of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. According to the DSM-IV, a GAF scale includes scores ranging between zero and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the rating issue; rather, the GAF 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). Scores ranging from 51-60 are appropriate where there are, "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)." DSM-IV. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. A GAF score of 31 to 40 indicates the examinee has some impairment in reality testing or communication or major impairment in several areas, such as work or school. Id. Analysis After careful consideration of all of the evidence of record, including particularly the above-referenced VA PTSD examination reports dated in January 2009, April 2011, and May 2012, together with the numerous VA outpatient psychiatric-based medical records on file, the Board finds that the Veteran's PTSD did not warrant a rating in excess of 30 percent at any time from October 23, 2008, to December 6, 2009. The Board also finds that from April 27, 2011, a disability rating in excess of 70 percent is not for application. The Board, however, does find that the evidence of record demonstrates that, from December 7, 2009, to April 26, 2011, a disability rating of 50 percent, but no higher, is warranted for the Veteran's service-connected PTSD. In this regard, between October 23, 2008, through December 6, 2009, the medical evidence of record fails to demonstrate that the criteria set out in 38 C.F.R. § 4.130 (Diagnostic Code 9411), and necessary for the assignment of a 50 percent (or higher) rating, had been met. Review of the January 2009 VA PTSD examination report, while acknowledging that the Veteran complained of memory loss and panic attacks, reasoning and judgment were described as fair. The Veteran also did not report having suicidal or homicidal ideation. Further, a GAF score of 60 was provided. As noted, a GAF score of 51 to 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). See DSM- IV. Also, the symptoms shown to affect the level of the Veteran's occupational and social impairment, included among the VA outpatient medical records dated from October 23, 2008, through December 6, 2009, are not shown to be comparable to those contemplated in the criteria to be productive of the degree of occupational and social impairment warranting a rating in excess of 30 percent. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Accordingly, a rating in excess of 30 percent is not warranted for the PTSD for the period from October 23, 2008, to December 6, 2009. The Board does find, however, that for the period from December 7, 2009, to April 26, 2011, a rating of 70 percent, but no higher, is warranted for the Veteran's service-connected PTSD. On review of the findings set out as part of the medical evidence on file dated during this time period, and documented above, the Board finds that several VA outpatient medical records (dated December 7, 2009, February 2010, March 2010, and October 2010), all include GAF score findings of 45. This is representational of serious symptoms or a serious impairment in social, occupational, or school functioning. Also, on December 7, 2009, the Veteran's mood was "stressed," and in March 2010 the Veteran complained of increasing panic attacks over the past few months. His mood was again reported to be "stressed." For this same period, however, the symptoms comparable to that contemplated in the criteria to be productive of the degree of occupational and social impairment necessary for the assignment of a 100 percent rating, such 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 were not demonstrated. These findings indicate to the Board a severity of psychological, social, and occupational functioning well below the severity necessary for the assignment of a 100 percent rating for the period from December 7, 2009, to April 26, 2011. See above-cited GAF score information; DSM-IV. Finally, the Board is of the opinion that, as indicated above, that from April 27, 2011, and after considering all of the pertinent evidence of record, including particularly the VA examination report dated April 27, 2011, and the May 2012 VA examination report, the Veteran's service-connected PTSD does not warrant a disability rating in excess of 70 percent rating. In this regard, the Board finds particularly noteworthy that while a GAF score of 40 was provided by the VA examiner in April 2011 (indicative of some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood), the examiner also characterized the level of severity of the Veteran's PTSD as that being consistent with the precise wording in Diagnostic Code 9411 pertaining to a 70 percent rating. Also, both the April 27, 2011, VA examination report, as well as the report of the VA PTSD examination afforded the Veteran in May 2012, fail to present a disability picture which more nearly approximates the criteria for a 100 percent rating. Specifically, neither the GAF score of 40 supplied in the course of both examinations, nor the GAF scores of 45 supplied later (in November 2011, and June and September 2012) are demonstrative of sufficient symptomatology upon which to base the assignment of a 100 percent rating. Also, while in the course of the April 2011 VA examination the Veteran reported having homicidal ideation and delusions and hallucinations, at no time has medical findings since April 27, 2011, reflected total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; 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; or memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Accordingly, the preponderance of the evidence is against a 100 percent evaluation at any time during from April 27, 2011. In reaching these decisions, the Board considered the doctrine of reasonable doubt, however, where the preponderance of the evidence is against the appellant's claims (in part), the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration The Board has also considered referral for extra-schedular consideration. Ordinarily, the VA rating schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). 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, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, concerning the Veteran's service-connected PTSD now on appeal, the evidence in this case does not show such an exceptional disability picture that the available respective schedular evaluation is inadequate. The Board further observes that, even if the available schedular evaluation for the disability was inadequate (which it is not), there is no evidence in the medical records of an exceptional or unusual clinical picture. The record does not show that the Veteran required frequent hospitalization for his PTSD. Also, while it was noted in the May 2012 VA PTSD examination report that the Veteran had not recently attended school or looked for work, the record is devoid of an opinion that indicates that the Veteran was unable to work due to his PTSD. To this, the Board observes that the VA examiner in May 2012 commented that the Veteran, with appropriate psychotherapeutic intervention, should be capable of improved functioning with the possibility of securing and maintaining gainful employment. The Board does parenthetically observe that in August 2012 the RO granted entitlement to TDIU. Therefore, the Board finds that the criteria for submission for assignment of extra-schedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In this case, there is no competent evidence of an exceptional or unusual clinical presentation in the record. For these above-stated reasons, the Board finds that referral of the Veteran's case for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. ORDER An initial disability rating in excess of 30 percent for PTSD from October 23, 2008, to December 6, 2009, is denied. From December 7, 2009, to April 26, 2011, a 70 percent staged rating, but no higher, for PTSD is granted, subject to the provisions governing the award of monetary benefits. A disability rating in excess of 70 percent for PTSD from April 27, 2011, is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs