Citation Nr: 1325187 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 09-06 260 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to December 2, 2011. 2. Entitlement to a staged initial rating in excess of 50 percent for service-connected PTSD from December 2, 2011. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.M. Seay, Associate Counsel INTRODUCTION The Veteran had active service from September 1965 to September 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Augusta, Maine, wherein the RO granted service connection for PTSD and assigned an initial disability rating of 30 percent, effective June 29, 2007. The case is now under the jurisdiction of the Detroit, Michigan RO. In October 2011, the Board remanded the Veteran's claim for a higher initial disability rating for PTSD for further evidentiary development. In a June 2012 rating decision, the Appeals Management Center (AMC) granted a higher initial rating of 50 percent, effective from December 2, 2011. In doing so, "staged" ratings have been created and the Veteran's PTSD claim has been bifurcated as shown on the title page. As this increase does not represent the maximum benefits sought, the Veteran's claim is not abrogated and remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993) (finding that where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The issue of entitlement to service connection for alcohol dependence claimed as secondary to service-connected PTSD has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The Board is cognizant of the ruling of the United States Court of Appeals for Veterans' Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on individual unemployability due to service-connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. During an August 2011 video-conference hearing before the undersigned Veterans Law Judge, the Veteran testified that he felt that he would not be able to procure employment due to his PTSD. However, following this testimony, a March 2012 rating decision denied entitlement to a TDIU. The Veteran did not appeal the decision. Since the March 2012 rating decision, neither the record nor the Veteran has indicated that he is unemployable due to the issue on appeal. Accordingly, the Board concludes that a claim for a TDIU is not for appellate consideration. FINDING OF FACT Since the initial grant of service connection, the Veteran's PTSD has been manifested by anxiety, depression, irritability, intrusive thoughts, nightmares, hypervigilance, social isolation, panic attacks, survivor guilt, flashbacks, avoidance of crowds, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, impaired impulse control with periods of violence, difficulty in adapting to stressful circumstances, productive of functional impairment comparable to no worse than occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 50 percent, but no higher, for service-connected PTSD, prior to December 2, 2011, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an initial rating in excess of 50 percent for service-connected PTSD, from December 2, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS VA has a duty to notify and assist veterans in substantiating a claim 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). Duty to Notify Here, the Veteran is appealing the initial rating assignment as to PTSD. Once service connection has been granted, the context in which the claim initially arose, the claim has been substantiated; therefore, additional VCAA notice under § 5103(a) is not required because the initial intended purpose of the notice has been fulfilled, so any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Rather, thereafter, once a notice of disagreement (NOD) has been filed, for example contesting a downstream issue such as the initial rating assigned for the disability, only the notice requirements for a rating decision and statement of the case (SOC) described in 38 U.S.C. §§ 5104 and 7105 control as to the further communications with the Veteran, including as to what evidence is necessary to establish a more favorable decision with respect to downstream elements of the claim. 38 C.F.R. § 3.159(b)(3) (2012). The RO has provided the Veteran the required SOC discussing the reasons and bases for not assigning a higher initial rating and citing the applicable statutes and regulations. Duty to Assist The duty to assist the Veteran has also been satisfied in this case. The service treatment records and VA medical treatment records have been obtained and associated with the claims file. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA treatment records were obtained pursuant to the Board's October 2011 remand and, therefore, the remand directive was completed. Stegall v. West, 11 Vet. App. 268 (1998). The record does not reflect that the Veteran is in receipt of non-age related benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2); Golz v. Shinseki, 590 F.3d 1317, 1320-21 (Fed. Cir. 2010). The Veteran was provided with two VA examinations with regard to his claim. The Board finds that the VA examinations are adequate. The examiners performed mental status examinations of the Veteran, considered the Veteran's reported symptomatology, and provided the medical information necessary to address the rating criteria in this case. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Thus, the Board's October 2011 remand directive was completed. See Stegall, 11 Vet. App. 268 (1998). In addition, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disability since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Finally, there is no indication in the record that additional evidence relevant to the issue being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court recently held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ explained the issue on appeal and the VLJ and the Veteran's representative asked the Veteran questions to ascertain the nature of his current PTSD and the existence of any potentially available outstanding evidence that would help substantiate the claim. In addition, the VLJ pointed out the additional records of treatment at the Saginaw, Michigan VA Medical Center and solicited information from the Veteran regarding his treatment. Indeed, the Board's October 2011 remand requested that the identified VA treatment records be obtained. As noted above, the records are now associated with the claims file. The hearing focused on the symptoms the Veteran associated with his PTSD and the effect these symptoms have on his ability to function occupationally, socially, and in his daily life. Neither the Veteran nor his representative has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c) (2). Initial Rating Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Specific schedular criteria for rating mental disorders PTSD is rated by applying the criteria in 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). The VA Schedule rating formula for mental disorders reads in pertinent part as follows: 30 percent - 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, or mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. 50 percent - 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. Id. 70 percent - Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 100 percent rating (the maximum schedular rating) - 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. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, consideration is given to all symptoms of the Veteran's PTSD that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). 38 C.F.R. § 4.125 (2012). If the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Global Assessment of Functioning (GAF) GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). According to the pertinent sections of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV), a GAF score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). A GAF score of 31 to 40 indicates 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). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence for the rating period on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. In the present claim, there are hundreds of pages of clinical records with regard to the Veteran's symptoms. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to his claim. Service connection has been established for PTSD effective from June 29, 2007. The Veteran's PTSD was assigned an initial disability rating of 30 percent, effective June 29, 2007. During the appeal period, the Veteran's initial rating for PTSD was increased to 50 percent, effective December 2, 2011. Therefore, the issue before the Board is whether the Veteran's PTSD is entitled to an initial rating in excess of 30 percent prior to December 2, 2011 and whether the Veteran's PTSD is entitled to an initial rating in excess of 50 percent on and after December 2, 2011. An appeal from the assignment of an initial disability rating, such as this case, requires consideration of the entire time period involved, and contemplate staged ratings where warranted. See Fenderson, supra. The VA treatment records reveal GAF scores ranging from 55 to 60. In addition, the Veteran complained of anxiety, depression, intrusive thoughts, irritability, and sleep impairment. In some records, the Veteran noted that he tried to stay socially connected, but other records indicate that the Veteran preferred to be alone and was socially isolated. The Veteran was provided a VA examination in January 2008. The Veteran reported experiencing psychiatric symptoms to include intrusive thoughts, sleep disturbance, and restlessness. He stated that he used to over-work in the past as one way of keeping busy to deal with his PTSD from his Vietnam War experiences. On mental status examination, the Veteran was alert and oriented times 3. His mood was slightly anxious. With respect to communication, there was no mania and no pressured speech. He was not suicidal or homicidal and his dress and hygiene were adequate. There were no hallucinations and no delusions. He complained of some intrusive thoughts and occasional flashbacks of being mortared and attacked. He reported some survivor guilt when they accidently hit another American unit. He complained of anxiety attacks and nervousness. He remembered three out of three words at three minutes. He spelled the word world forward and backward with one error backward. The examiner determined that the Veteran met the DSM-IV criteria for PTSD based on his Vietnam War experiences. The examiner noted that the Veteran had some social dysfunction and restlessness in the past. The examiner listed a GAF score of 55. During the August 2011 video conference hearing, the Veteran testified that he felt that he developed a stronger sense of his PTSD since he stopped working in 2005. He stated that he did not like being in crowds and he felt irritable and angry. He testified that he did not have any friends come to his house and he had basically been isolated for at least the past two to three years. He stated that he retired due to his cardiac disability and not his PTSD. He then stated that he felt his PTSD interfered with his ability to work "probably a little bit" because he flew off the handle quicker at people. He felt that just considering the PTSD alone, it could preclude him from holding a job to a certain extent. He reported that he was not forthcoming during the January 2008 VA examination with respect to the nature and extent of his PTSD symptomatology. The Veteran was provided a VA examination in December 2011. The GAF score was listed as 50. The examiner indicated that the Veteran's PTSD manifested in occupational and social impairment with reduced reliability and productivity. The Veteran reported that he remained married to his wife of over 40 years and that his relationship was "going pretty good" despite the fact that he spent much of his time alone or drinking at the American Legion. The Veteran had a good relationship with his daughter, two stepchildren, and grand and great-grandchildren with family gatherings approximately once a year. He stated that he and his wife used to golf during the summers, but in recent years, he was less interested in doing so. The Veteran related that he had many acquaintances at the American Legion but no close friendships. Most of his interactions were fairly superficial and centered around alcohol use. The Veteran reported that he retired at 60 instead of his intended retirement at 62, shortly after his bypass surgery in 2004. From 2006 to 2008, he worked as a bartender part-time at the American Legion. It gradually turned into a full time job, but the Veteran finally retired completely in June 2008. The Veteran attended monthly counseling sessions at VA since 2007. He stated that he was prescribed Citalopram to help cool his quick temper. He stated that he was an alcoholic and consumes three to four drinks each night. He reported depression and stated that he grabbed a man by the neck who was degrading the Marines and the Vietnam War. He stated that his wife said he was ornery and gets mad too easily. He reported sleep impairment with nightmares and that his was often troubled by intrusive memories. He also reported chronic anxiety and was distressed from itching. On mental status examination, the Veteran was alert and oriented and displayed no gross memory impairments or difficulties with concentration. He interacted pleasantly despite his visible anxiety and self-consciousness. His mood was subdued and his affect was generally flat, but congruent to content. He displayed mild to moderate psychomotor agitation. His speech was normal in rate and tone and his speech was spontaneous and goal directed. His thought processes were organized with no evidence of formal thought disorder, hallucinations, delusions, or obsessive-compulsive features. He appeared to be of average intelligence, capable of abstract thinking, and displayed fair insight into his PTSD and related emotions and behaviors. The Veteran displayed no difficulties with activities of daily living and denied suicidal or homicidal ideation or full-blown panic attacks. He stated that he had periodic episodes of increased anxiety and tended to withdraw from others to prevent escalation of his symptoms. The examiner indicated that the Veteran experienced the following symptoms: anxiety, depressed mood, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner stated that the results of the current examination revealed moderate to severe signs of symptoms of PTSD including daily intrusive thoughts, frequent nightmares with chronically disrupted sleep, persistent attempts to avoid talking or thinking about his combat experiences, moderate emotional numbing and distancing from others, irritability with occasional angry outbursts, and continued hyperarousal and hypervigilance. The examiner also noted the Veteran's history of chronic alcohol dependence since his return from Vietnam. The examiner explained that the Veteran relied on alcohol to tamp down his memories and emotions from his experiences in Vietnam. In consideration of the above, the Board finds that the Veteran's PTSD warrants a higher initial disability rating of 50 percent for the entire period on appeal. Although the Veteran does not meet all the criteria set forth for a 50 percent rating, it is not required that all of the enumerated criteria be met for a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The record shows that the Veteran is socially isolated, exhibits flattened affect, has disturbances of motivation and mood to include depression and anxiety, and difficulty in establishing and maintaining relationships. During the video conference hearing, the Veteran testified that he did not have friends over and that he was isolated. In addition, the Veteran reported that he was irritable. The Board notes that the December 2011 VA examination report includes a more detailed description of the Veteran's symptoms as opposed to the January 2008 VA examination. However, the Veteran reported that he was not as forthcoming during the January 2008 VA examination. The December 2011 VA examiner also explained that the Veteran's symptoms have remained stable since the 2008 VA examination-indicating that the Veteran exhibited these symptoms throughout the period on appeal. Therefore, by resolving the benefit-of-the-doubt in favor of the Veteran, an initial 50 percent rating is warranted for the entire appeal period. 38 U.S.C.A. § 5107(b). However, the Board finds that the Veteran's PTSD is not entitled to an initial rating in excess of 50 percent at any time during the appeal period. The overall symptomatology associated with the Veteran's PTSD does not more closely approximate the schedular criteria required for the next higher 70 percent disability rating. The medical evidence does not reflect that the Veteran's PTSD manifestations are productive of functional impairment comparable to occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. As examples, the evidence does not show that the Veteran has experienced symptoms such 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; spatial disorientation; neglect of personal appearance and hygiene; and inability to establish and maintain effective relationships. The medical evidence shows that the Veteran's speech has exhibited some mild to moderate psychomotor agitation. However, the speech has not been illogical, obscure, or irrelevant. In fact, his speech has been noted as goal directed and normal. The evidence shows that the Veteran has been oriented to person, place, and time and his appearance was adequate. Furthermore, although the record shows that the Veteran suffers from depression, the evidence does not establish that his depression affects his ability to function independently. There is no evidence of any obsessional behavior which interferes with routine activities. Finally, the evidence indicates that the Veteran may have difficulty in adapting to stressful circumstances (including work or worklike setting) and the Veteran has had instances of impaired impulse control. Indeed, the Veteran stated that he had problems controlling his temper and he grabbed a man by the neck who was degrading the Marines and the Vietnam War. However, even considering such symptoms, in considering the whole disability picture and overall evidence, the Board finds that the Veteran's symptoms are productive of functional impairment which most closely approximates the assigned 50 percent disability rating. In regard to family and social life, the record shows that the Veteran tries to avoid most people and is isolated. In reviewing the record, it is clear that the Veteran has social impairment; however, it does not establish that the Veteran has an inability to maintain or establish relationships. For instance, although the Veteran tends to socially isolate, he also goes to the American Legion Post to spend time with others. Although the relationships were noted to be superficial by the most recent VA examiner, it is nonetheless relevant with respect to social functioning. In addition, the evidence indicates that the Veteran is still married and the August 2011 VA treatment record noted that the Veteran continued to stay active and socially connected. As for evidence regarding work relationships, the record shows that the Veteran is retired. The Veteran has reported that PTSD would interfere with his job because he was more likely to fly off the handle; the Board finds that any difficulties with work are taken into account by the 50 percent disability rating. As such, the Board finds that the Veteran's social and occupational impairment is more accurately associated with the 50 percent disability rating. Finally, the Veteran is not entitled to a 100 percent rating for any period of time covered by the appeal. In this regard, the Veteran does not allege, nor does the evidence of record demonstrate total occupational and social impairment as a result of his service-connected PTSD. There is no indication that the Veteran's PTSD has manifested in symptoms productive of functional impairment comparable to such level of impairment. As examples, there has been no demonstration of 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. Accordingly, a 100 percent rating is not warranted for any period of time covered by this appeal. 38 C.F.R. § 4.130. In addition, the Veteran has been assigned GAF scores ranging from 50 to 60. GAF scores ranging from 51 to 60 reflect more 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 obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Here, the Board notes that the most recent VA examiner listed a GAF score of 50, indicating serious impairment and symptoms. In reviewing all of the Veteran's PTSD symptoms, the Board finds that the Veteran has exhibited more moderate symptoms with moderate difficulty in social and occupational functioning, rather than the more serious symptoms associated with the lower GAF score, such as obsessional rituals and no friends. More importantly, as noted above, a GAF score is only one component of a Veteran's disability picture, and the Board finds that the clinical findings are consistent with the current rating of 50 percent. The Board has considered the benefit-of-the-doubt doctrine; however, the preponderance of the evidence is against the assignment of an initial rating in excess of 50 percent for PTSD. Thus, the benefit-of-the-doubt doctrine is not applicable and the claim is denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). The Board has also considered referral for extraschedular consideration. Ordinarily, the VA 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 in Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's symptoms with the established criteria found in the rating schedule for mental disorders shows that the rating criteria reasonably describe ratings for mental disorders. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly 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 has required frequent hospitalizations for his service-connected disability. In addition, the evidence does not indicate that the above condition markedly interferes with the Veteran's ability to work. In fact, the Veteran stated that he retired due to his cardiac disability. Although the Veteran stated that his PTSD would interfere with his occupation because he was more likely to fly off the handle and that his PTSD would impact his ability to procure a job to a certain extent, the Board does not find that the PTSD markedly interferes with the Veteran's ability to work. While it is undisputed that the disability affects the Veteran's employment, it bears emphasis that the schedular rating criteria are designed to take such factors into account. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. Therefore, the Board finds that the criteria for submission for assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to an initial rating of 50 percent, but no higher, for service-connected PTSD is granted for the entire period on appeal prior to December 2, 2011, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial rating in excess of 50 percent for service-connected PTSD, from December 2, 2011, is denied. ______________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs