Citation Nr: 1325342 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 10-12 222 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to an initial evaluation in excess of 70 percent for posttraumatic stress disorder. REPRESENTATION Appellant represented by: Military Order of the Purple Heart WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from September 1967 to July 1970. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. This case was previously before the Board in May 2011 and September 2012, on which occasions it was remanded for additional development. The case is now, once more, before the Board for appellate review. While in remand status, a 70 percent rating for PTSD from the date of the claim was assigned. A total rating based on individual unemployability has also been assigned. The appeal for an initial rating in excess of 70 percent continues. FINDING OF FACT The Veteran's service-connected posttraumatic stress disorder is currently productive of no more than occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and/or an inability to establish and maintain effective relationships. Total social and industrial impairment has not been shown at any time during the appeal process. CONCLUSION OF LAW The criteria for an initial evaluation in excess of 70 percent for posttraumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130 and Part 4, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) In the case at hand, inasmuch as service connection, an initial rating, and an effective date have been assigned, the notice requirements of 38 U.S.C.A. § 5103(a) (West 2002) have been met. Moreover, VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claim, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. Finally, in reaching this determination, the Board has reviewed all the evidence in the Veteran's claims file, which includes his multiple contentions, offered during the course of a hearing before the undersigned Veterans Law Judge in September 2010, as well as both VA and private treatment records and examination reports, and various statements by the Veteran's family members and former associates. 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 Veteran's claim, and what the evidence in the claims file shows, or fails to show, with respect to that 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). Analysis The Veteran in this case seeks an increased evaluation for service-connected posttraumatic stress disorder. In pertinent part, it is contended that manifestations of that disability are more severe than presently evaluated, and productive of a greater degree of impairment than is reflected by the 70 percent schedular evaluation now assigned. In that regard, disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two evaluations apply, the higher evaluation will be assigned where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). While the Board must consider the Veteran's medical history as required by various provisions under 38 C.F.R. Part 4, including 38 C.F.R. § 4.2 [see Schafrath v. Derwinski, 1 Vet. App. 589 (1991)], the degree of impairment resulting from a service-connected disability is a factual determination, with the Board's primary focus in such cases being upon the current severity of the service-connected disability. See Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the Francisco rule does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an award of service connection for the disability in question. Rather, at the time of the initial rating, separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Accordingly, the analysis in this decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). Ratings are to be based as far as practicable upon the average impairment of earning capacity, with the additional proviso that the Secretary shall, from time to time, readjust the schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in 38 C.F.R. § 3.321 (2012) an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture, with such related factors as a marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular standards. In the case at hand, in a rating decision of June 2008, the RO granted service connection (and a 10 percent evaluation) for posttraumatic stress disorder, effective from November 30, 2007, the date of receipt of the Veteran's initial claim for service connection. The Veteran voiced his disagreement with that assignment of benefits, with the result that, in a rating decision of February 2013, the RO awarded a 70 percent evaluation for service-connected posttraumatic stress disorder, once again effective from November 30, 2007. The current appeal ensued. In a VA psychology consultation of September 2007, the Veteran reported that, immediately following his discharge from service, he was "very anxious" and experienced significant sleep disruption, as well as intense social isolation. However, over the course of the next two years, the Veteran's friends were able to incorporate him back into society, with the result that he began working part-time at a number of odd jobs. Following that period, the Veteran was able to secure employment as a marble mason with a local marble company, where he worked for a few years. Reportedly, following that employment, the Veteran worked for Gulf Oil for the next three years. However, the Veteran subsequently decided to return to the local marble company where he had been working as a marble mason. Significantly, according to the Veteran, he had worked at that marble company for the past 26 years on a full-time basis. Moreover, the Veteran denied having any difficulties on the job, including disciplinary actions. According to the examiner, the Veteran appeared to have been quite successful financially, being able to support his family with consistent employment over the years. Regarding his past psychiatric history, the Veteran reported that, ever since his return from Vietnam, he had experienced sleep disruption. However, he had never sought treatment for his symptoms, and appeared to have been able to persevere both occupationally as well as socially without treatment. According to the Veteran, since 2003, he had noticed an increase in his symptomatology, most notably, in sleep disruption. On mental status examination, the Veteran presented as somewhat anxious, though in general, he was able to provide good information. The Veteran employed good eye contact throughout the evaluation, and both hygiene and appearance were described as adequate and appropriate to the setting and situation. The Veteran's rate of speech was within normal limits, and his thought processes were logical, sequential, and goal-directed. At the time of evaluation, there did not appear to be any delusional thought content. Nor was there any evidence of a formal psychotic process. The Veteran's insight and judgment were described as good. While according to the Veteran, he had been experiencing significant difficulties with concentration on the job, this was not evident by his performance on serial 7's backwards from 100. The Veteran was well oriented, and demonstrated adequate abstracting ability. Moreover, he denied both auditory and visual hallucinations, and similarly denied ever having had experienced homicidal ideation, intent, or plan. While the Veteran did note problems with fleeting suicidal ideation, he indicated that he utilized "self talk" to talk himself out of harming himself, citing his family as his current reason for living. Significantly, the Veteran had never made a suicide attempt, and did not appear to have ever formulated a specific suicide plan. With regard to his symptoms, the Veteran reported having experienced a sad and anxious mood. Additionally noted were problems with sleep disruption, though the Veteran denied any initial or late insomnia. According to the Veteran, he at times experienced irritability. However, he denied any history of verbal or physical aggression towards others. In the opinion of the examiner, based on all objective measures and the Veteran's symptom presentation, it appeared that he had been experiencing increased symptoms following his return from Vietnam for the first two years, but that these symptoms had largely remitted up until the onset of the Iraq war. The Veteran reported that he had experienced an increased number of intrusive thoughts and recollections since 2003, which was why he was currently requesting assistance. However, in the opinion of the examiner, the Veteran appeared to have relative control over many of his symptoms. The pertinent diagnosis noted was posttraumatic stress disorder, in partial remission, characterized by slight impairment in occupational functioning due to decreased concentration on the job, as well as slight social withdrawal. The Global Assessment of Functioning Score assigned was 70. During the course of VA outpatient treatment in early March 2008, it was noted that the Veteran had been tolerating his medication with no side effects. Additionally noted was that the Veteran found his medication beneficial, resulting in a decrease in angry outbursts and agitation, as well as in his level of anxiety and nightmares. On mental status examination, the Veteran was well groomed, cooperative, and well engaged, with normal speech, and a "good" mood. Additionally noted was that the Veteran's affect was somewhat brighter, and that his thought processes were logical. At the time of evaluation, there was no evidence of any disturbance of thought content. Nor was there any evidence of suicidal or homicidal ideation, or any perceptual disturbance. The Veteran's cognition was grossly intact, as were his insight and judgment. The pertinent diagnosis noted was chronic posttraumatic stress disorder, characterized by mild impairment in occupational functioning and social withdrawal. The Global Assessment of Functioning Score was 75. At the time of a VA psychological examination in late March 2008, it was noted that the Veteran's claims folder and medical records were available, and had been reviewed. When questioned, the Veteran indicated that he had consistently worked for a local marble company since the early 1980's. Moreover, the Veteran denied ever having been fired from any position. According to the Veteran, he had good working relationships with his co-workers and supervisors, and his work performance was generally good. Moreover, the Veteran denied any significant time lost from work or decreased work productivity due to his psychiatric symptoms. When questioned regarding how he spent his time, the Veteran indicated that, when not working, he spent his time doing household chores and running errands. According to the Veteran, he drove and cooked, and was independent in the activities of daily living. Significantly, the Veteran indicated that he had been married to his wife for 26 years. When questioned regarding his social relationships, the Veteran reported that he had friends at The American Legion, and that he socialized with them on Friday nights. Additionally noted was that the Veteran volunteered two Sundays per month to cook breakfast at The American Legion, and that he attended church services on a weekly basis. Moreover, according to the Veteran, he had frequent contact with his siblings. On mental status examination, the Veteran was alert and well oriented, and both pleasant and cooperative. The Veteran was casually dressed in his work clothes, and both hygiene and grooming were described as fair. According to the examiner, the Veteran's speech was fluent, coherent, and normal in rate and volume. While the Veteran's mood was extremely anxious, characterized by brief tearfulness when discussing his guilt feelings and stressors from Vietnam, his affect was normal in range and appropriate to content. Significantly, when questioned regarding his mood symptoms, the Veteran described himself as "moody," and indicated that he became sad when he thought about Vietnam. The Veteran endorsed irritability, but denied any physical altercations. Additionally reported were problems with poor concentration, as well as decreased sexual libido. While the Veteran reported occasional suicidal ideation, he denied any plan or intent, and similarly denied any history of suicide attempts. At the time of evaluation, no manic episodes were reported. When further questioned, the Veteran indicated that he was anxious on a daily basis, and tended to worry and ruminate about stressors. However, he denied any history of recurrent panic attacks, and similarly denied any obsessions or compulsive behaviors. Significantly, the Veteran denied any inappropriate or reckless behaviors. His ideation was relevant and goal-directed, and no psychotic symptoms were in evidence. Moreover, the Veteran denied any history of hallucinations or paranoia. The Veteran's gross cognitive functioning appeared adequate, and both insight and judgment appeared to be fair. The pertinent diagnosis noted was chronic mild posttraumatic stress disorder resulting in problems with occupational functioning. The Global Assessment of Functioning Score was 70. By the Veteran's own admission, his symptoms appeared to be having a mild impact on his social and occupational functioning, although he had been able to maintain gainful employment for many years without significant occupational impairment. In the opinion of the examiner, the Veteran remained "fully employable." Moreover, the current severity of the Veteran's psychiatric symptomatology would not significantly impair his financial decisionmaking ability. During the course of VA outpatient treatment in early January 2010, the Veteran indicated that he had "good and bad days." According to the Veteran, he preferred to be alone, and usually avoided people, though he was able to deal appropriately with them when necessary. Reportedly, the Veteran could sometimes be irritable, though he could still control himself. On mental status examination, the Veteran was well groomed, alert, oriented, and cooperative. While the Veteran did exhibit some anxiety, and explicitly stated that he felt anxious, he displayed a normal level of motor activity, as well as good eye contact. The Veteran's speech was characterized by a normal volume, rate, rhythm, and tone, and his affect was appropriate and coherent, though generally restrained. At the time of evaluation, there was no evidence of any hallucinatory behavior or depersonalization. The Veteran's thought processes were well directed and coherent, and the content of his thought was appropriate. While there was evidence of some mild cognitive distortion, as well as somatic preoccupation, the Veteran displayed no evidence of suicidal ideation, or thoughts of harming others. Cognitive function was characterized by good memory, attention, and concentration, and the Veteran understood both his condition and the usefulness of his treatment. The pertinent diagnosis noted was chronic posttraumatic stress disorder, with a Global Assessment of Functioning Score of 70. In correspondence of September 2010, a VA physician indicated that the Veteran continued to have difficulty with intrusive combat memories, social isolation, and hyperarousal. According to that physician, the Veteran had experienced difficulty managing his temper and irritability at work, with the result that he had walked off his job of 30 years in early June amid a fear that his temper would lead to his "hurting someone." As a result, the Veteran was not currently employed. However, he was managing his hyperarousal with medication and avoidance of social situations. According to the VA physician, the Veteran's difficulties were consistent with combat-related posttraumatic stress disorder. At the time of a subsequent VA psychological examination in June 2011, it was noted that the Veteran's claims folder was available, and reviewed in detail prior to the examination. According to the examiner, at the time of the Veteran's last evaluation, he had reported good working relationships with his co-workers and supervisors, as well as generally good work performance. Moreover, the Veteran had denied any significant time lost from work as a result of decreased work productivity due to psychiatric symptoms. However, when questioned, the Veteran indicated that he had left the marble company for which he had been working in May of 2010, essentially "walking off the job." According to the examiner, the Veteran's description of his reason for leaving work appeared unclear. More specifically, given that the Veteran had reported no difficulty of any kind with work at the time of his 2008 examination, his report of having problems beginning in 2006 and 2007 appeared inconsistent. Significantly, the Veteran appeared to be reporting anger at his employer for not allowing him time off from work for reasons which were unclear. However, given that the Veteran was apparently able to get a pension through his union following his departure, it was unclear whether or not the Veteran's leaving work was considered a retirement. In the opinion of the examiner, there appeared to be some inconsistencies in the Veteran's presentation regarding his symptoms interfering with work versus the prior report in 2008, where the Veteran appeared to be working well with no difficulties. On mental status examination, the Veteran's dress was casual and appropriate, and his clothing both clean and reasonably well fitting. Grooming and hygiene were adequate, and orientation good. At the time of examination, the Veteran was alert and responsive in overall activity level, though somewhat restless and tense. Moreover, the Veteran was at times rather intrusive, often wishing to talk repeatedly about his wartime experiences to the exclusion of answering questions which had been directly posed to him. Eye contact was described as fair, and the Veteran's speech was normal in volume and tone, though rapid in rhythm and rate. Speech content was overproductive and tangential, and at times difficult to direct. At the time of examination, the Veteran's mood appeared to be anxious, with a somewhat labile affect, though at times, this appeared to be presented in an overly dramatic fashion. The Veteran's appetite was reportedly low, though his weight had remained stable. Sleep was described as erratic, with the Veteran claiming to have nightmares five to six times a night, which to the examiner appeared to be extremely excessive, and most likely an exaggeration. Regarding suicidal ideation, the Veteran denied any thoughts of harming himself. Thought processes appeared to be at times somewhat perseverative and concrete, though with no evidence of cognitive impairment. At the time of examination, there was no evidence of any hallucinations or delusions. Nor were any dissociative symptoms reported. While the Veteran did admit to locking the doors of his house at night, he denied any specific obsessive-compulsive behaviors. According to the examiner, overall, the Veteran appeared to engage in some social activities, though he was somewhat vague regarding his socialization. Significantly, insight and judgment did not appear to be impaired. Regarding the Veteran's activities, it was noted that, at the time of his prior examination in 2008, the Veteran appeared to engage in social activities such as attending church and being involved in a small church group, as well as having frequent contact with his siblings and volunteering two Sundays a month to cook breakfast at The American Legion. Moreover, the Veteran had previously reported that, at times, he socialized with his friends regularly on Friday nights. However, according to the examiner, this appeared to "significantly change" after the Veteran was informed that these were the reasons for his being denied an increase in his service-connected posttraumatic stress disorder. The pertinent diagnosis noted was chronic mild posttraumatic stress disorder, characterized by mild symptoms accompanied by some difficulty in social or occupational functioning, with a Global Assessment of Functioning Score of 65. In the opinion of the examiner, the Veteran's current evaluation was generally consistent with his prior examination, though with some indication of a mild increase in reported symptomatology. However, it was important to note that the Veteran on several occasions appeared to be somewhat overemphasizing his symptoms, and that some of his reported difficulties with symptoms and symptom onset appeared to be inconsistent with those reported in 2008. More specifically, while the Veteran specifically reported a downward turn in his functioning beginning in 2006 and 2007 when contacted by former Veterans from his unit, this was clearly contradicted by the previous report of his level of functioning, both occupationally and socially. According to the examiner, while the Veteran was now reporting significant social withdrawal, as well as leaving his job, this appeared to coincide with the most recent denial of increased benefits for his service-connected posttraumatic stress disorder. Moreover, progress notes from the Veteran's various treatment providers appeared to reflect a similar pattern. Overall, the Veteran's treatment notes suggested some mild increase in symptoms over the course of the past year, in contrast to his period of overall stable symptomatology and, at least in some cases, remission of that symptomatology. According to the examiner, while there appeared to have been some mild increase in the Veteran's overall symptomatology, this increase did not appear to be at the level the Veteran was currently portraying in his verbal report and in testing. Significantly, psychological testing clearly suggested symptom overreporting, with the Veteran continuing to be employable for psychiatric purposes. In fact, in the opinion of the examiner, the Veteran did not require any special accommodations or schedules in order to maintain employment. Significantly, the Veteran reported no history of reckless or impulsive behaviors, and was capable of attending to the activities of daily living. Moreover, at the time of evaluation, there was no evidence of any impairment in communication secondary to psychiatric symptoms. In summary, the results of the Veteran's current evaluation in conjunction with evaluation of his medical records and claims folder suggested only some mild exacerbation or increase in symptoms of social withdrawal, as well as some increased difficulty in sleep disturbance and overall anxiety. Significantly, the Veteran appeared to be overreporting some of his symptoms, in particular, those concerning depression and intrusive recollections. During the course of VA outpatient psychiatric treatment in March 2012, the Veteran indicated that he was feeling better, having recently been approved for Social Security disability benefits. According to the Veteran, this eliminated a significant amount of the financial pressure on his family. However, he was "still frustrated" at the length of time it had taken the VA to determine the "amount of service connection for his posttraumatic stress disorder." When questioned, the Veteran described occasional anger outbursts, but noted that his outbursts had recently decreased. While according to the Veteran, he still isolated himself, his family was able to reach out to him. Reportedly, the Veteran was currently sleeping four to five hours a night, and was "fine with this." His main complaint had to do with having to ask physicians to exert pressure on policymakers regarding his posttraumatic stress disorder. On mental status examination, the Veteran's appearance was described as disheveled, though equal to his stated age. The Veteran was casually dressed, displayed good eye contact, with no evidence of any abnormal movements. The Veteran's affect was bright, and his speech was normal in tone, volume, rate, fluency, and quality. Thought processes were linear and goal-directed, and the Veteran denied both suicidal and homicidal ideation. Similarly denied was any evidence of delusions, or auditory or visual hallucinations. The Veteran was grossly oriented and attentive throughout the psychiatric interview. Recent and remote memory appeared intact, and both insight and judgment were fair. The pertinent diagnosis noted was posttraumatic stress disorder, with a Global Assessment of Functioning Score of 55. In an addendum of May 2012, the same VA psychologist who had performed the June 2011 examination indicated that, based on his review of previous examinations and subsequent available medical records, the Veteran's symptoms of posttraumatic stress disorder had resulted in 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). Further noted was that, on previous examination, there was substantial evidence suggesting symptom overreporting, in which the Veteran's test responses indicated an attempt to portray a level of functioning more impaired than historical information would indicate. However, both VA examinations, in 2008 and 2011, yielded consistent Global Assessment of Functioning Scores and impressions regarding the Veteran's overall level of functioning and employability. In Veterans Resource Center correspondence dated in June 2012, it was noted that the Veteran continued to experience difficulties with nightmares and intrusive thoughts related to his combat experiences in Vietnam. Additionally noted were problems with intense anxiety and panic attacks, as well as periods of depression and sleep disturbance. Reportedly, the Veteran's Global Assessment of Functioning Scale bordered between moderate and serious symptoms at 51, as did his Focus Severity Rating for posttraumatic stress disorder. In correspondence of June 2012, a VA physician wrote that the Veteran continued to experience problems with nightmares, as well as intrusive memories of combat in Vietnam. Reportedly, the Veteran now slept in a separate room from his wife due to his frequently "moving around" in his sleep. According to the VA physician, the Veteran remained in treatment for his posttraumatic stress disorder. Moreover, in the opinion of the VA physician, the Veteran remained unable to maintain gainful employment, with the result that he was now receiving Social Security disability benefits for combat-related posttraumatic stress disorder. Pursuant to applicable law and regulation, the 70 percent evaluation currently in effect for the Veteran's service-connected posttraumatic stress disorder contemplates the presence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and/or an inability to establish and maintain effective relationships. In contrast, a 100 percent evaluation requires demonstrated evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting oneself or others; intermittent inability to perform the activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, one's own occupation, or one's own name. 38 C.F.R. § 4.130 and Part 4, Diagnostic Code 9411 (2012). Global Assessment of Functioning Scores are 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 the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), page 32]. A Global Assessment of Functioning Score of between 51 and 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)." A Global Assessment of Functioning Score of between 61 and 70 is defined as "some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships." A Global Assessment of Functioning Score of between 71 and 80 is defined as "if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork)." While the Rating Schedule does indicate that the rating agency must be familiar with the Diagnostic and Statistical Manual of Mental Disorders, it does not assign disability percentages based solely on Global Assessment of Functioning Scores. See 38 C.F.R. § 4.130 (2012). Rather, Global Assessment of Functioning Scores are but one factor to be considered in conjunction with all other pertinent evidence of record. At the outset, it should be noted that the Veteran is currently in receipt of a total disability rating based upon individual unemployability. However, it is clear that no more than a 70 percent evaluation is warranted for the Veteran's service-connected posttraumatic stress disorder. More specifically, at no time during the course of the current appeal has the Veteran exhibited symptomatology consistent with or indicative of a 100 percent evaluation, such as gross impairment in thought processes, persistent delusions or hallucinations, grossly inappropriate behavior, disorientation to time and place, or memory loss. Rather, for the period in question, the Veteran has most often been described as alert and well oriented, with no evidence of any cognitive impairment, and no dissociative symptoms. Significantly, at the time of the aforementioned VA examination in March 2008, the Veteran indicated that his symptoms had only a mild impact on his social and occupational functioning. Moreover, as of the time of a more recent VA examination in June 2011, it was the opinion of the examiner that the Veteran's presentation showed only some mild exacerbation or increase in symptoms of social withdrawal, in conjunction with increased difficulty in sleep disturbance and overall anxiety, such that the Veteran continued to be employable for psychiatric purposes, and required no special accommodations or schedules in order to maintain employment. Significantly, according to the examiner, the Veteran appeared to be overreporting certain of his psychiatric symptoms, in particular, those concerning depression and intrusive recollections. Based on the aforementioned, the Board is of the opinion that the 70 percent evaluation currently in effect for the Veteran's service-connected posttraumatic stress disorder is appropriate, and that an increased rating is not warranted. Accordingly, the Veteran's claim for an increased evaluation must be denied. Moreover, based on a review of the entire evidence of record, the Board is of the opinion that the disability picture presented by the Veteran's service-connected posttraumatic stress disorder is appropriately contemplated by the Rating Schedule, and that referral for consideration of an extraschedular evaluation is, therefore, not warranted. See Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). ORDER An initial evaluation in excess of 70 percent for service-connected posttraumatic stress disorder is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs