Citation Nr: 1325373 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 08-11 904 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to a disability evaluation in excess of 10 percent for shell fragment wound of the left leg, Muscle Group XI. 2. Entitlement to an initial disability evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to August 7, 2012, and in excess of 50 thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his son ATTORNEY FOR THE BOARD E. I. Velez, Counsel INTRODUCTION The Veteran had active service from May 1951 to February 1953. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in January 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. Jurisdiction has since been transferred to the RO in Los Angeles, California. In May 2012, the Veteran testified in a videoconference hearing before the undersigned. A copy of the transcript is in the claims file. In June 2012, the Board remanded the claim fro further development. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). In the present case, entitlement to TDIU, has been granted in a rating decision of June 2013 effective August 7, 2012. The record does not reflect that the Veteran has filed expressed disagreement with the effective date assigned for this action. As such, the issue of entitlement to TDIU is not before the Board. A review of the Virtual VA paperless claims processing system shows additional records have been associated with the claim. The records contained therein have been considered in the decision below. FINDINGS OF FACT 1. Impairment of Muscle Group XI is shown, with fatigue and pain, a lowered threshold of fatigue, and impaired prolonged ambulation; however, there is normal muscle strength, and no evidence of muscle atrophy, fascial defects, or impairment of muscle tonus; and the condition does not affect the muscle substance or function. 2. Prior to August 7, 2012, the Veteran's PTSD was manifested by nightmares, impaired affect, depression, hypervigilance, difficulty in understanding complex commands, avoidance tendencies, irritability, mild to moderate memory impairment, isolative tendencies, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships 3. Occupational and social impairment with deficiencies in most areas is not shown at any point during the appeal period. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for shell fragment wound left leg, Muscle Group XI, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.56, 4.73, Diagnostic Code 5311 (2012). 2. PTSD is 50 percent disabling effective May 5, 2006. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for entitlement to an evaluation in excess of 50 percent for PTSD, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that or "immediately after" VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Pelegrini at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). With regards to the PTSD, the Veteran's claim arises from his disagreement with the initial disability rating following the grant of service connection for PTSD. It has been held that once service connection is granted, the claim is substantiated and additional notice is not required. Thus any defect in the notice provided to the Veteran is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Nevertheless and with regards to the shell fragment wound to the left leg, by a letter dated in June 2006 (prior to the initial rating decision), the RO notified the Veteran of the evidence necessary to substantiate his claims; the information that he needed to provide; and the information or evidence that VA would attempt to obtain. In an August 2012 letter, he was provided with notice of how VA assigns disability ratings and effective dates. This letter did not predate the rating decision. However, the timing error is harmless as the claim was subsequently readjudicated in a supplemental statement of the case of July 2013. VA further has a duty to assist. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. That is, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). Here, VA obtained all relevant records and associated these with the claims file. VA provided the Veteran with appropriate VA examinations. The VA examination reports described the disability in sufficient detail to rate the disabilities under the appropriate diagnostic criteria so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991). See also, Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); D'Aries v. Peake, 22 Vet. App. 97, 104 (2008). Therefore, the Board concludes that there was substantial compliance with the directives contained in the Board's prior remand decision. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Moreover, a videoconference hearing was held. Therefore, the Board finds that the VA has satisfied its duties to notify and to assist the claimant in this case. No further assistance to the veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). Legal Criteria and Analysis Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating the severity of a particular disability it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). A claim such as in the claim for an increased evaluation for PTSD, placed in appellate status by disagreement with the initial rating award and not yet ultimately resolved, is an original claim as opposed to a new claim for increase. Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. In evaluating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). A. Left Leg At a VA examination in June 2006, the Veteran reported he experiences constant pain in the left leg which travels to through entire leg. The pain was described as squeezing, aching, sharp and cramping in nature with pain level is an 8 out of 10. Symptoms could be elicited by cold and physical activity. At the time of pain, the Veteran could function with medication. He denied any numbness in the legs. He had to stop walking after a block and a half due to cramps in order to relieve the cramping. The Veteran complained of loss of strength, weakness, easy fatigability and pain. The injury caused limitation in walking and he could not keep up with work as it required standing for long periods of time. Examination revealed a level scar at the middle of the left calf measuring 6 cm by 0.4 cm with hypopigmentation of less than six square inches. There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, Keloid formation, hyperpigmentation and abnormal texture. Posture and gait were within normal limits. There was no intermuscular scarring and no adhesion to the bone. There was a Muscle Group XI wound present. Palpation of the muscle reveals loss of deep fascia and impairment of muscle tone. Strength is graded at 4/5. The injury does not affect the function of the particular body part it controls and there is no muscle herniation. Range of motion of the left knee was flexion to 140 degrees and extension of 0 degrees. Anterior and posterior cruciate ligaments, and medial and lateral ligaments were within normal limits. Left leg x-rays showed a small radiodense foreign body proximal dorsal soft tissue and mild osteopenia. At a VA examination in August 2011, the Veteran reported constant pain in the left leg that traveled to the knee and foot. The pain was burning, aching, sharp and cramping and is of an intensity of 8 out of 10 and could be exacerbated by physical activity and cold weather. His symptoms would come on spontaneously. At the time of pain, he could function without medication. He complained of weakness, easy fatigability and pain. He denied any loss of strength, impairment of coordination and inability to control movements. There were complications from the injury including intermuscular scarring, but without prolonged infections and adhesion of scars to the bone. The Veteran had difficulty with prolonged standing and walking. Examination revealed a scar on the posterior side of the left leg which was linear and measured 7 cm by 0.5 cm. The scar was not painful, had no breakdown, and was superficial with no underlying tissue damage and no inflammation. There was no edema, keloid formation, or disfiguring. The scar did not limit motion or function. Posture was normal but the Veteran walked with an antalgic gait due to his left leg. He also had an unsteady tandem gait. Examination of the feet revealed no evidence of abnormal weight bearing or breakdown. He used a cane for ambulation. Palpation of Muscle Group XI revealed no loss of deep fascia or muscle substance and no impairment of muscle tone. There was a muscle wound present with no adherence of the underlying structures, no intermuscular scarring and no adhesions to bone. There were no signs of lowered endurance or impaired coordination. Strength is 5 and there was no muscle herniation. The examiner observed that the muscle injury did not involve any tendon, bone, joint or nerve damage. Examination of the knee showed tenderness on the medial side of the knee. Range of motion was flexion to 120 degrees and extension to 0 degrees with no change on repetitive use. The ankle had normal range of motion with no additional loss of motion on repetitive use. Neurological examination was normal. At the May 2012 hearing the Veteran testified he occasionally uses a cane for ambulation. He denied any treatment for his leg except for muscle ointments and massages he administers himself. He denied any problems with the scar, but stated he was limited to walking 3 or 4 blocks. His son testified that he had seen the Veteran fall due to weakness of his leg. At a VA examination of July 2012, the Veteran reported he walked with a limp with associated muscle cramping that led to frequent falls, about twice a month. The cramping seemed to be aggravated with cold weather and abrupt types of movements such as propulsion of his foot. Significant weakness with dorsi and plantar flexion of the left foot was noted. On examination small linear scars were noted. There was no evidence of fascial defects associated with the injury. The injury did not affect muscle substance or function. There was consistent loss of power, consistent weakness, consistent lowered threshold of fatigue, consistent impairment of coordination, and consistent uncertainty of movement. Muscle strength was 3/5 in the left leg. There was no muscle atrophy. The Veteran used a cane for ambulation. There was no functional impairment of an extremity which would equal amputation. Distal pulses were intact. Sensation was decreased in the left medial lower leg with significant decreased range of motion of the ankle. The scar was linear, nonpainful, nonkeloidal with no hyperpigmentation and measures 5.5 cm by 0.5 cm. The examiner noted the injury significantly affected the Veteran's his ability to work. VA regulations provide that slight muscle disability is generally found where there has been a simple wound of the muscle without debridement or infection. 38 C.F.R. § 4.56. Clinical examination would disclose the absence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue would be present. Moderate muscle disability is found where there has been a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. There must be indications of some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. Moderately severe muscle disability is found where there has been through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. There must be indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with the sound side must demonstrate positive evidence of impairment. With severe muscle disability, there is evidence of wide damage to muscle groups in the missile track. There must be indications on palpation of loss of deep fascia or muscle substance, or soft, flabby muscles in the wound area. There must be severe impairment of function, that is, strength, endurance and coordination, of the involved muscle group. In addition, X-ray evidence of minute multiple scattered foreign bodies, or visible evidence of atrophy, may indicate a severe muscle disability. 38 C.F.R. § 4.56. 38 C.F.R. § 4.73, Diagnostic Code 5311, provides that disability of the posterior and lateral crural muscles, and muscles of the calf due to a muscle injury to Muscle Group XI, is rated as noncompensable if slight, at 10 percent if moderate, at 20 percent if moderately severe, and at 30 percent if severe. Based on the results of the examinations above, at worst, the impairment of Muscle Group XI is shown with fatigue and pain, a lowered threshold of fatigue impairment of coordination, weakness, uncertainty of movement, and impaired prolonged ambulation, with moderate loss of strength (3/5). However, there is no evidence of muscle atrophy, fascial defects, or impairment of muscle tonus; and the condition was found not to affect the muscle substance or function. The Board acknowledges that at the June 2006 VA examination the Veteran was noted to have loss of deep fascia and muscle tone. However, the same were not present at the two subsequent VA examinations. Therefore, the Board finds that the overall disability picture and weight of the evidence does not reflect that there has been a consistent loss of deep fascia or loss of muscle tone. As a result, the preponderance of the evidence shows that the next higher rating of 20 percent for moderately severe disability of Muscle Group XI is not warranted. There was not a through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring, or other injury of similar initial severity. The Board notes that while the June 2006 and May 2012 VA examinations noted no intermuscular scarring, the August 2011 examination noted intermuscular scarring but no prolonged infections or adhesions to the bone. As noted above, there are no indications on palpation of consistent loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. The symptomatology noted is directly contemplated under the criteria for the currently assigned rating of 10 percent, corresponding to moderate muscle disability. See 38 C.F.R. §§ 4.56, 4.73, Diagnostic Code 5311. The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected disability of Muscle Group XI. The governing norm in such exceptional cases is: 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 as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the Veteran's symptoms are fully contemplated in the rating schedule. There is nothing to indicate that the disability picture is exceptional or unusual. Accordingly, referral to the Director, Compensation and Pension, is not warranted. In light of the foregoing, the Board finds that the preponderance of the evidence is against a rating in excess of the currently assigned 10 percent rating for service-connected disability of Muscle Group XI of the left lower extremity. For no period are the criteria for the next higher rating of 20 percent met or approximated. Thus, a "staged" rating in excess of 10 percent for disability of Muscle Group XI is not warranted for any period pertinent to this appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). As the preponderance of the evidence is against the claim for a rating in excess of 10 percent for shell fragment wound of the left leg, Muscle Group XI, the benefit of the doubt doctrine is not for application. See generally Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. PTSD The Veteran's psychiatric disorder is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 [PTSD] (2012). PTSD is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. The pertinent provisions of 38 C.F.R. § 4.130 concerning the rating of psychiatric disabilities read in pertinent part as follows: 100 percent: 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 and place; memory loss for names of close relatives, own occupation or name. 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. 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; difficulty establishing effective work and social relationships. 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, and mild memory loss (such as forgetting names, directions, recent events). See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Global Assessment of Functioning (GAF) 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 FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. 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). 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). See 38 C.F.R. § 4.130 (2012) [incorporating by reference the VA's adoption of the DSM-IV for rating purposes]. The Veteran's service-connected PTSD and bipolar disorder is currently rated 30 percent disabling prior to August 7, 2012 and as 50 percent thereafter. Treatment records form the Vet Center dated in April 2006 show a GAF score of 50. Moreover, Vet Center records dated between April 2006 and November 2007 note the Veteran started with a GAF score of 35 and left with a GAF score of 40. At a June 2006 VA examination, the Veteran reported he had trouble sleeping and feeling depressed. The examiner noted the Veteran got tearful and began sobbing as soon as they started the interview especially when talking about his experiences during the Korean War. The Veteran reported having crying spells, depression, nervousness, anxiety, tearfulness and recollections. The symptoms were constant. He reported it affected his social and work functioning; and said he did not have any friends and the only family member he spent time with was his wife. Further, he preferred to be by himself. On mental status examination he was noted to have normal orientation, appearance and hygiene were appropriate. Mood and affect were abnormal; he is anxious and depressed. He was noted to be irritable, have impaired impulse control and has outbursts of anger. Communication and speech were normal. He denied any panic attacks, delusions or hallucinations. Ritualistic obsessions were absent and thought process was normal. Memory was mildly to moderately abnormal. There were no suicidal or homicidal ideations. He was diagnosed with PTSD and assigned a GAF score of 63. The examiner noted that his PTSD symptoms are mild to moderate and that he has difficulty in establishing and maintaining work and social relationships, and there is a decrease in work efficiency especially during stressful periods. He has difficulty with complex commands. VA outpatient treatment records of March 2007 note a GAF score of 55. Mental status examination showed dysphoric mood with tearful affect. Speech was slow with a heavy accent. Thought content was logical, but it appeared he had problems organizing information and expressing what was relevant. Memory was questionable. Insight and judgment were also questionable. There were no suicidal or homicidal ideations. At a VA examination of August 2011, the Veteran reported symptoms of paranoid thoughts, anxiety, flashbacks, nightmare, irritability, hypervigilence and a tendency to isolate. The severity of the symptoms was moderate. Symptoms were constant, ongoing and continuous. The Veteran reported the symptoms affected his total daily functioning. He denied a history of suicidal attempts. Mental status examination showed orientation was within normal limits. Appearance, hygiene and behavior were appropriate. Affect and mood were normal. Communication, speech, and concentration were within normal limits. There were no panic attacks. There was no history or evidence of delusions, hallucinations or obsessive compulsive behavior. Thought processes were appropriate and judgment was not impaired. Abstract thinking was normal and memory was within normal limits. There were no suicidal or homicidal thoughts. A GAF score of 56 was assigned for moderate mental symptoms and impairment. At the May 2012 hearing the Veteran testified that he liked to be alone, felt irritable at times, and had flashbacks of his stressors. He took medication for his symptoms. He further testified of crying spells that occurred twice a month. These happen suddenly. He also testified he no longer did anything with friends. At a VA examination of August 2012, the Veteran reported problems sleeping, startled responses, avoidance tendencies and strong feelings of grief and sorrow. The examiner noted he had occupational and social impairment with reduced reliability and productivity. The examiner noted that while the ability to work had not been affected, his social functioning had been. Intrusive reminders, emotional distress, avoidance reminders, and chronic psychological arousal have been chronic symptoms in his life. He is more socially isolated and less interested in having friends. The examiner noted symptoms of recurrent distressing dreams, intense psychological distress, reactivity to external stimuli, avoidance tendencies, markedly diminished interest or participation in significant activities., difficulty sleeping, exaggerated startle response, anxiety, depressed mood, mild memory loss, impairment of short- and long- term memory, and impaired abstract thinking. He was assigned a GAF score of 50. At the outset the Board notes that the Veteran is appealing the original assignment of a disability evaluation following an award of service connection for PTSD. In such cases, the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). In January 2007, the RO granted service connection for PTSD and assigned a 30 percent evaluation effective May 5, 2006, the date of the claim. In a rating decision of June 2013, the AMC increased the Veteran's evaluation of PTSD to 50 percent disabling effective August 7, 2012. Therefore, the Veteran has been assigned a staged rating. Clearly a staged rating may be assigned when appropriate. Regulations establish that different examiners, at different times, will not describe the same disability in the same language. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history. When any change in evaluation is to be made the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in thoroughness of the examination. See 38 C.F.R. §§ 4.2, 4.13. The Board has been presented with differing medical reports and the Veteran's own statements. Throughout the appeal period, the Veteran has asserted that his service-connected PTSD is worse. In this case, the Board concludes that during the course of the appeal, there has not been an actual change in the degree of disability and a staged rating is not warranted. Upon review of the evidence above the Board finds that throughout the appeal period, the evidence more nearly approximates a 50 percent evaluation for PTSD. However, an evaluation in excess of 50 percent is not warranted. After a careful review of the evidence of record the Board finds that an evaluation in excess of 30 percent for PTSD prior to August 7, 2012 is warranted as the Veteran's symptoms more closely approximate a 50 percent evaluation. Prior to August 2012, the evidence shows the Veteran's PTSD was characterized mostly by symptoms of anxiety, depression, tearfulness, irritability, problems sleeping impaired impulse control, abnormal memory avoidance and isolation. Indeed, the Veteran for the most part, did not associate with anyone except his children and spouse. He had no friends and preferred to stay at home. His GAF score were consistently noted to be around 50-56, reflective of moderate to serious symptoms, except for the June 2006 VA examination in which the GAF score was noted to be 63. However, the Board finds that the symptoms described within the June 2006 examination report are more severe than those reflected in a GAF score of 63. The Board places greater weight on the symptoms noted than the GAF score assigned. Significantly, the June 2006 and August 2011 VA examiners both described the Veteran's symptoms to be up to moderate and both noted the Veteran's PTSD moderately affected his social functioning. While the Veteran does not have all of the symptomatology consistent with the assignment of a 50 percent rating prior to August 7, 2012, the Board finds that the impact of the Veteran's PTSD on his social and industrial functioning is sufficient to approximate the degree of impairment contemplated by a 50 percent rating prior to August 7, 2012. See 38 C.F.R. § 4.7 (2012). Based on the evidence of record, the Board concludes that symptomatology which warrants an increased rating of 50 percent is approximated prior to August 7, 2012. See 38 C.F.R. § 4.7 (2012). The assignment of the 50 percent evaluation prior to August 7, 2012 now creates a uniform rating. However, the Board must still consider whether a higher evaluation is now warranted for any time frame. For the reasons expressed immediately below, the Board has determined that the evidence does not support a conclusion that the Veteran has symptoms of occupational and social impairment, which would warrant a disability rating in excess of 50 percent. In this regard the Board notes that, as discussed above, the Veteran has had periods of impaired impulse control, and has reported that he has difficulty working and interacting with others, indicating difficulty adapting to stressful circumstances. However, the Veteran's VA mental health evaluations and treatment records do not indicate suicidal ideation, illogical, obscure, or irrelevant speech or near-continuous panic or depression affecting the ability to function independently. Nor is there evidence of spatial disorientation, neglect of personal appearance and hygiene, or obsessional rituals which interfere with routine activities. Finally, although the Veteran has indicated that he is unable to establish and maintain effective relationships, the Board notes that multiple VA treatment records, to include the VA examination reports, document his continuous relationship with members of his family and attendance at VA group therapy. As such, inability to establish and maintain effective relationships has not been demonstrated. In light of the foregoing, the Board concludes that, while the Veteran demonstrates a few of the criteria listed for a disability rating in excess of 50 percent, the evidence of record does not show that his overall level of severity closely approximates the criteria for a disability rating in excess of 50 percent under 38 C.F.R. § 4.130. Moreover, there are no other factors which would lead the Board to conclude that a disability rating in excess of 50 percent is warranted. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) [the specified factors for each incremental rating are examples rather than requirements for a particular rating; analysis should not be limited solely to whether the claimant exhibited the symptoms listed in the rating scheme]. A review of the medical evidence indicates that the Veteran's psychiatric symptomatology centers on his depression, anxiety, nightmares, avoidance, irritability, mildly to moderately impaired memory, hypervigilance, impaired concentration, panic attacks, disturbances of mood and motivation, and difficulty establishing work and social relationships. These symptoms are more congruent with the assigned 50 percent disability rating. Thus, a review of the evidence clearly indicates that symptomatology associated with the Veteran's PTSD most closely approximates that which allows for the assignment of a 50 percent disability rating for the entire appeal period, but no more. See 38 C.F.R. § 4.7 (2012). A disability rating in excess of 50 percent is not warranted. The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected disability of Muscle Group XI. The governing norm in such exceptional cases is: 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 as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the Veteran's symptoms are fully contemplated in the rating schedule. There is nothing to indicate that the disability picture is exceptional or unusual. Accordingly, referral to the Director, Compensation and Pension, is not warranted. ORDER Entitlement to a rating in excess of 10 percent for shell fragment wound of the left leg, Muscle Group XI, is denied. Prior to August 7, 2012, entitlement to a 50 percent rating for PTSD is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a rating in excess of 50 percent for PTSD is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs