Citation Nr: 1325589 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 07-27 542 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to October 7, 2009, and in excess of 50 percent thereafter. REPRESENTATION Veteran represented by: Robert V. Chisolm, Attorney-At-Law WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran had active service with the United States Army from March 1971 to April 1972, to include a tour of duty in Vietnam. He is in receipt of a Combat Infantryman Badge (CIB). This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied service connection for a skin disorder and granted service connection for PTSD, with a 30 percent evaluation effective from July 26, 2006. The Veteran and his wife presented testimony at a personal hearing before the undersigned Acting Veterans Law Judge in June 2010. A transcript is of record. Additional evidence has been associated with the Veteran's claims folder, along with a waiver of initial RO consideration. In September 2010, the Board remanded the claims for service connection for a skin disorder and an initial rating in excess of 30 percent for PTSD for additional development. The issue of entitlement to a TDIU was referred to the agency of original jurisdiction (AOJ) for adjudication in the first instance. The RO did not take any action on the claim for a TDIU. In a decision dated October 2012, the Board denied the Veteran's claim of entitlement to an initial disability rating in excess of 30 percent prior to October 7, 2009 for PTSD, granted a 50 percent rating from October 7, 2009, and denied a disability rating in excess of 50 percent from October 7, 2009. The Board also remanded the Veteran's skin disorder and TDIU claims to the AOJ for evidentiary development; as TDIU is considered part of the claim for an increased initial rating for PTSD, the Board assumed jurisdiction over it. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran appealed the Board's decision as to his PTSD claim to the United States Court of Appeals for Veterans Claims (Court). In January 2013 the parties to the appeal filed a Joint Motion for Remand (JMR). The Court granted the motion, vacated the Board's decision, and remanded the matter for further proceedings. Accordingly, the Veteran's VA claims folder has been returned to the Board for further appellate proceedings. The RO did not have an opportunity to process the Board's remand with regard to TDIU and service connection for a skin disorder due to the appeal to the Court, and so those issues have not yet been returned to the Board for further action. The prior, October 2012 Remand with regard to those issues is therefore referred to the RO. The Board also notes that in assigning the Veteran a 50 percent disability rating for PTSD from October 7, 2009 in the October 2012 decision, the RO incorrectly assigned an effective date of October 14, 2009 in an October 2012 rating decision. The Board has reviewed the Veteran's claims folder and the record maintained in the Virtual VA paperless claims processing system. FINDINGS OF FACT 1. Prior to October 7, 2009, the Veteran's PTSD was not manifested by occupational and social impairment with reduced reliability and productivity, nor have other symptoms on par with the level of this severity been shown. 2. From October 7, 2009, the Veteran's PTSD has not been manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, nor have other symptoms on par with the level of this severity been shown. CONCLUSION OF LAW Entitlement to an initial rating in excess of 30 percent for PTSD prior to October 7, 2009, and in excess of 50 percent thereafter is denied. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran seeks entitlement to an initial rating in excess of 30 percent for PTSD prior to October 7, 2009, and in excess of 50 percent thereafter. In the interest of clarity, the Board will discuss certain preliminary matters. The issue on appeal will then be analyzed and a decision rendered. Compliance with the Court's Directives As was noted in the Introduction, the Veteran's increased rating claim involves a JMR by the Court. The Board wishes to make it clear that it is aware of the Court's instructions in Fletcher v. Derwinski, 1 Vet. App. 394, 397 (1991), to the effect that a remand by the Court is not "merely for the purposes of rewriting the opinion so that it will superficially comply with the 'reasons or bases' requirement of 38 U.S.C.A. § 7104(d)(1). A remand is meant to entail a critical examination of the justification for the decision." The Board's analysis has been undertaken with that obligation in mind. The January 2012 JMR found that, in granting in part and denying in part the Veteran's increased disability claim, the Board focused on the exemplary symptoms listed in the rating criteria rather than the overall level of impairment. The Court specifically referenced its decision in Mauerhan v. Principi, 16 Vet. App. 436 (2002), in which it held that "the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the [Diagnostic Code]. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment[.]" Accordingly, remand was warranted in order for the Board to provide an adequate statement of reasons or bases for its decision. The Board is confident that if any additional problems existed, the Court would have brought them to the Board's attention. See Harris v. Derwinski, 1 Vet. App.180, 183 (1991) (holding that the "Court will (not) review BVA decisions in a piecemeal fashion"). VA's Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence necessary to substantiate the claim and the division of responsibilities in obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, the Veteran is disagreeing with the rating assigned after service connection has been granted and an initial disability rating and effective date have been assigned. Thus the service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has obtained service treatment records, assisted the Veteran in obtaining evidence, to include records from the Social Security Administration (SSA), afforded the Veteran appropriate examinations to determine the severity of his disability, and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Higher evaluation for PTSD 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; 38 C.F.R. Part 4. Separate rating codes identify various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. See generally 38 C.F.R. §§ 4.1, 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). Service connection for PTSD was initially granted pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, with a 30 percent rating effective July 26, 2006. See February 2007 rating decision. The rating was subsequently increased to 50 percent effective October 7, 2009 via an October 2012 Board decision. The Veteran testified that he is entitled to an increased rating because his PTSD has worsened. He reported having to quit work (but described it as just not being able to deal with the people and the drudgery rather than quitting as a result of any one incident); problems with interpersonal relationships, to include lashing out at people at work and getting into arguments; sinking into worsened depression to the point of not wanting to do anything; not wanting to be involved in much of anything, to include crowds of people; and constantly thinking about his service experience. The Veteran indicated that he had quit work the June prior and had not sought employment since then as he had problems getting along with authority. He reported that he was receiving treatment in the form of individual sessions and had been prescribed medication for anxiety. The Veteran described an average day as getting out of bed and not feeling like doing much of anything such that he sits around and watches television or goes out to the garage to sit for a while. He indicated that he occasionally mowed the yard and that he goes to church on Sunday, but did not have many scheduled activities. The Veteran also reported problems finishing things he has started. He indicated that he had had problems with people at church, to include lashing out at the pastor and getting into an argument with the pastor's wife. He also noted disagreements with other people and having to go back to apologize. The Veteran reported physical confrontations in the past, mostly at his place of employment. He indicated a sense of feeling worthless and feeling that life does not have much meaning, but denied suicidal ideation. See June 2010 hearing transcript. The Board finds the Veteran's testimony both competent and credible. The Veteran's wife testified that he has trouble finishing many of the jobs he starts; does not want to leave the house; and has begun doing things that he had never done in their nearly forty year marriage, such as overdrawing the checking account, leaving his keys in the car with the windows open, when he used to be obsessive about things like that, leaving his lawn mower outside rather than putting it away like he used to, and leaving their garage door open. She essentially pointed out his forgetfulness, but also indicated that even if the Veteran realizes he has forgotten to do something, he will not feel like taking care of it. She also reported that he has told her on several occasions that he has gotten confused as to where he was while driving, which scared her, described obsessive behaviors at night, such as checking the doors to make sure they are locked, and indicated that he had gotten more irritable, frustrated, and verbally abusive. Id. The Board finds the Veteran's wife's testimony both competent and credible. Pursuant to the General Rating Formula for Mental Disorders, a 30 percent evaluation is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 50 percent evaluation is warranted when there is 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 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 in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation contemplates occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. Id. Lastly, a 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting 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 name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994) (DSM-IV). A GAF score of 11 to 20 indicates that there is some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement), an occasional failure to maintain minimal personal hygiene, or gross impairment in communication. A GAF of 21 to 30 is defined as behavior considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriate, suicidal preoccupation) or an inability to function in almost all areas (e.g., stays in bed all day, no job, home or friends). A GAF of 31 to 40 is assigned where there is "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; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 61 to 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, has some meaningful interpersonal relationships. A GAF score generally reflects an examiner's finding as to the Veteran's functioning score on that day and, like an examiner's assessment of the severity of a condition, is not dispositive. Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2012). Use of terminology such as "moderate" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The evidence in this case includes VA and private treatment records, records associated with the Veteran's claim for benefits from the SSA, and several VA examination reports. A September 2006 mental health outpatient treatment plan note reveals that the Veteran was being seen for the first time. He was married and working in maintenance from 6am to 2:30pm, after which he would watch television from 3:30pm to 9:30pm. He indicated that he had been distant with his older brother up to the present and that his younger brother and both parents were deceased. Depressive symptoms and trauma history and related anxiety symptoms were noted to be active foci of mental health treatment. The Veteran reported trauma-related memories or nightmares and flashbacks or dissociative episodes a few times per week. The Veteran underwent a VA initial evaluation for PTSD examination in December 2006, during which he reported that he had been married for 34 years to his only wife, had a GED, and was working in a factory where he had been doing maintenance for the past three and one-half years. The Veteran reported receiving mental health treatment for the past two to three years through VA and that he was taking medications to help with sleep disturbance and to improve his mood. His current symptoms included depression; feeling useless, but not suicidal; middle insomnia; an inability to finish projects; difficulty concentrating; persistent thoughts of Vietnam; and flashbacks. He denied nightmares, but reported that his wife indicated that he had a history of nightmares, and also denied and any problems with alcohol or drugs. The Veteran reported that his depression kept him from doing a good job at work and that he had been separated three to four times from his wife, but that his marriage was ok at the present time. He indicated that he was able to engage in a normal range and variety of activities of daily living without interruption of his typical daily routine and that his leisure activities included going to church. Mental status examination revealed that the Veteran was somber and lethargic throughout the course of the examination. Thought processes were logical, coherent and relevant. The Veteran was described as an attractive, articulate, verbal, well-dressed and well-groomed individual who was overall mentally intact and cooperative. He was somewhat overweight but seemed intelligent and his speech was well understood. The Veteran was oriented to time, place, person and situation; affect was flat and blunted; and reasoning, fund of general information, verbal comprehension, and concentration were all described as good. The Veteran did not exhibit any psychomotor slowing or agitation but he reported that his short-term memory was poor and that sensorium was cloudy. He denied having any head trauma, seizures or stroke. A review of psychological symptoms resulted in the endorsement of anxiety, panic attacks, depression, insomnia, and appetite disturbance. The Veteran reported that he kept to himself and the examiner noted that he acted very depressed during the course of the psychological interview. The examiner reported that the Veteran's problem behaviors have to do mainly with his depression and his overall despondency. The Veteran indicated that he had never been suicidal but felt quite useless. He also had problems concentrating. It was the examiner's opinion that the Veteran was indeed depressed, had some obsessive tendencies, and may have problems concentrating because of the severity of his depression. Axis I diagnoses of PTSD with a GAF score of 65; major depressive disorder with a GAF score of 60; and undifferentiated somatoform disorder with a GAF score of 65, were assigned. The Veteran's overall GAF score was 65. The examiner reported that the Veteran's depression was partially related to his PTSD but his somatoform disorder was not related to either condition. The examiner also noted that the Veteran complained of a great deal of distress, stated that he felt useless, had a number of neurotic tendencies and engages in self defeating behavior. The examiner again noted that the depression was only partially related to PTSD and that such individuals (according to the MMPI) tend to be immature, egocentric and demanding, and that they channel unacceptable drives and urges into physical complaints. The examiner noted that the Veteran may actually be much better off than he realizes because he had had a steady job for many years and appeared to have a relatively stable marriage. A February 2007 mental health attending note reveals that the Veteran was seen for 30 minutes and reported compliance with his medication regimen. Medication had been helpful with his mood, which was rated at 4/5. Energy was low, the Veteran was sleeping 6-7 hours per night and his appetite was good. Interest had improved but was still low and the Veteran denied suicidal thoughts and any history of attempts. He also denied homicidal ideation and psychotic symptoms. He noted intrusive thoughts/memories on a daily basis, occasional nightmares, some avoidance behaviors, panic attacks every 1-2 months, and anxiety at a level 8/10. Mental status examination revealed constricted affect, low/slow speech, decreased psychomotor activity, and goal-directed thoughts. A GAF score of 55 was assigned. A November 2007 mental health attending note reveals that the Veteran was seen for 30 minutes, at which time he reported that he had run out of medication about a month ago and had noticed much increased depression and irritability. Mood was rated at 2/5, energy and interest were low, the Veteran was sleeping 4-5 hours per night with multiple awakenings, and appetite was somewhat low. The Veteran denied suicidal thoughts and any history of attempts and homicidal ideation. There were no psychotic symptoms. He noted intrusive thoughts/memories on a daily basis, occasional nightmares, some avoidance behaviors, panic attacks every 1-2 months, anxiety at a level 8/10, and increased irritability and worsened concentration, both of which had significantly impaired occupational stability. Mental status examination revealed constricted affect, low/slow speech, decreased psychomotor activity, and goal-directed thoughts. A GAF score of 55 was assigned. The Veteran was seen for a 30 minute medication management appointment in March 2008, the first time he was being seen at that clinic. He reported that his mood had been better and said his anxiety was better since a medication had been added, though he still had times when he felt anxious/depressed. The Veteran endorsed depressive ruminations, guilt feelings, recurrent intrusive thoughts about his trauma, but said he had not had nightmares for several months and had not had any recent panic attacks, the last one occurring two months prior. He denied suicidal and homicidal ideation, alcohol and drug abuse, and psychotic symptoms. The Veteran indicated that he slept about 4-5 hours per night mostly a function of needing to get up at 4am and not going to bed until late. He endorsed initial insomnia. His appetite was fair and taste for food was partially intact. See mental health attending note. In October 2008, the Veteran reported that he had run out of two medications the week prior and had noticed that he had been more irritable and was sleeping poorly. He was still feeling depressed with one of the medications and had poor energy and concentration. The Veteran also noted that he still felt hopeless at times. He was sleeping 4-5 hours per night and had no thoughts of suicide. Mental status examination revealed that he was clean, neatly dressed and well groomed. Behavior was cooperative and pleasant and he made good eye contact. Psychomotor activity was neither increased nor decreased. Speech was spontaneous, clear, and with appropriate volume and rate. Mood was depressed, affect was blunted, concentration was at an appropriate level, recent and remote memory were intact, and the Veteran was alert and oriented times four. Thought content was coherent, logical and goal oriented. There were no delusional or paranoid thoughts, no suicidal or homicidal ideation or intent, and no evidence of any auditory or visual hallucinations. Thought process was linear and insight and judgment were fair. A GAF score of 50 was assigned. See mental health attending note. The Veteran was seen for 30 minutes in January 2009, at which time he reported that he had been married since 1972 and was currently living with his wife and working in maintenance. He noted that he was having trouble at work due to irritability and was concerned that this could cost him his job. Mood was rated 2/5, energy was low, the Veteran was sleeping 5-6 hours per night, appetite was somewhat low and interest was low. The Veteran denied suicidal thoughts and a history of attempts but indicated that he felt worthless, sometimes hopeless. He denied homicidal ideation and psychotic symptoms. He reported intrusive thoughts/memories daily, occasional nightmares, anxiety at a level 8-9/10, some avoidance behaviors, panic attacks on a weekly basis, increased irritability and worsened concentration, both of which were significantly impairing his occupational stability. Mental status examination revealed constricted affect, low/slow speech, decreased psychomotor activity, and goal-directed thought processes. A GAF score of 55 was assigned. See mental health attending note. A May 2009 mental health attending note reveals that the Veteran reported continuing to feel depressed and irritable, was losing his temper easily at work, was feeling hopeless at times, and had poor energy. He was sleeping 6-7 hours per night and had occasional nightmares. Anxiety was well-controlled and he denied thoughts of suicide. Mental status examination revealed that he was clean, neatly dressed, and well groomed. Behavior was cooperative and pleasant. Eye contact was good and psychomotor activity was neither increased nor decreased. Speech was spontaneous and clear with appropriate volume and rate. Mood was depressed, affect was blunted, concentration was at an appropriate level, recent and remote memory were intact, thought content was coherent, logical and goal-oriented, and the Veteran was alert and oriented times four. There were no delusional or paranoid thoughts, no suicidal or homicidal ideation/intent, and no evidence of any auditory or visual hallucinations. Thought process was linear and insight and judgment were fair. Axis I diagnoses of PTSD and depressive disorder, not otherwise specified (NOS), were made and a GAF score of 50 was assigned. A July 2009 mental health assessment note reveals that the Veteran rated his depression at 3/10, which was an improvement due to medication increase, and indicated that he had no irritability, though his affect was apathetic, blunt and not reactive. Psychomotor retardation was positive, the Veteran was still bothered by thoughts of what happened in service and had remembered the incident three times since May 2009. He was sleeping 6-7 hours per night and had been laid off from his job, though he still had vacation time to cover and was going to look for another job. The Veteran denied irritability and indicated that anxiety was well-controlled. He denied suicidal or homicidal ideation. He was not psychotic or manic. Mental status examination revealed that he was alert, dysthymic, cooperative and pleasant. Speech was fluent, spontaneous and not pressured, the Veteran was well groomed and made good eye contact, and his affect was blunt without expression. The Veteran denied any aggressive behavior and thoughts of self-harm or harm to others. He also denied any auditory or visual hallucinations and delusions and psychotic symptoms. Thought content was coherent, logical, and goal-oriented and there were no delusional or paranoid thoughts. Thought process was linear and insight and judgment were fair. The Veteran was seen for 30 minutes in August 2009, at which time he reported being on short-term disability from work, with significant financial problems. Mood was rated 3/5, energy was low, the Veteran was sleeping 5-7 hours per night with occasional awakenings, and appetite and interest were low. He denied suicidal thoughts and a history of attempts and denied homicidal ideation. The Veteran noted daily intrusive thoughts/memories, occasional nightmares, anxiety at 8/10, some avoidance behaviors, and occasional panic attacks. Mental status examination revealed that the Veteran was appropriately groomed with constricted affect, low/slow speech, decreased psychomotor activity, and goal-directed thought processes. A GAF score of 55 was assigned. See mental health attending note. A SSA psychiatric assessment dated in September 2009 noted that the Veteran had a medically determinable impairment present that does not precisely satisfy diagnostic criteria but was noted to be depressive disorder NOS and PTSD. In terms of functional limitation, there was no restriction of activities of daily living or episodes of decompensation, each of extended duration; mild difficulties in maintaining social functioning; and moderate difficulties in maintaining concentration, persistence or pace. The findings from VA treatment records dated in January 2007, May 2009, and July 2009 were reported. The summary conclusions were as follows: the ability to remember locations and work-like procedures, the ability to understand and remember very short and simple instructions, the ability to carry out very short and simple instructions, the ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances, the ability to sustain an ordinary routine without special supervision, the ability to work in coordination with or proximity to others without being distracted by them, the ability to make simple work-related decisions, the ability to interact appropriately with the general public, the ability to ask simple questions or request assistance, the ability to accept instructions and respond appropriately to criticism from supervisors, the ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness, the ability to be aware of normal hazards and take appropriate precautions, the ability to travel in unfamiliar places or use public transportation, and the ability to set realistic goals or make plans independently of others were not significantly limited. The following were moderately limited: the ability to understand and remember detailed instructions, the ability to carry out detailed instructions, the ability to maintain attention and concentration for extended periods, the ability to complete a normal work day and worksheet without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods, the ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes, and the ability to respond appropriately to changes in the work setting. See Form SSA-4734-F4-SUP. In October 2009, the Veteran presented with headaches and weakness and dizziness. His wife sounded concerned about his mental status recently, and that was why a psych consult had been requested. The Veteran reported getting forgetful recently, forgetting names, things to do, and information he used to know in the past. He initially denied any psychiatric history, but later reported having PTSD and visiting a psychiatrist for the past one and one-half years. The Veteran sounded depressed and reported sadness and depressed mood sometimes with trouble sleeping but still getting a good amount of sleep (6-7 hours daily). He also reported decreased energy, anhedonia, poor ability to concentrate, and occasional hopeless and helplessness. Otherwise, he denied any suicidal or homicidal ideation and auditory or visual hallucinations or paranoia. The Veteran reported living with his wife, to whom he had been married for the last 35 years. They had two children and the Veteran was retired. He denied any drug, alcohol or smoking history. The Veteran reported flashbacks and nightmares. Mental status examination revealed that the Veteran was oriented to time, date, month, season, year, place and president. Immediate memory was 3/3 object and recent memory was 2/3 objects after four minutes. The Veteran had trouble with concentration at some points but managed to subtract 7 from 100 to the number 72. He spelled world backwards and mixed up the r and the o. The Veteran's wife reported very recent deterioration in the Veteran's mental status. In the last two weeks, he had been getting gradually more forgetful and had started to forget names, things to do, and information such as how much money he had in his wallet. She reported a similar episode in 1972 when he was admitted to a psychiatric hospital, but denied any other episodes. She could not predict how well his situation was going to be because he did not seem to be doing "well" to her. At the same time, she denied any suicidal and/or homicidal statements, and any aggression or physical violence, but reported that the Veteran could get really angry if things did not go the way he wanted or if he could not get himself "out of something." The examiner indicated that the Veteran was not at significant risk of self harm. The assessment was recent episode of forgetfulness with normal labs and negative CT scan of the head. It was also noted that the Veteran was not delirious, psychotic, suicidal or homicidal. He was also assessed with PTSD with hypervigilance, startling and flashbacks. See mental health resident on call note. A subsequent October 2009 mental health assessment note reveals that the Veteran was seen for follow-up after being treated in the emergency room. He denied suicidal or homicidal ideation and was not psychotic or manic. His wife accompanied him and reported a change in mental status due to medication (Abilify), but the Veteran indicated that the change was due to his fever and infection (for which he sought emergency room treatment). Mental status examination revealed that the Veteran was appropriately groomed and had constricted affect, low/slow speech and decreased psychomotor activity. Thought processes were goal-directed but interest was low. There were no suicidal thoughts or history of attempt and no homicidal ideation. The Veteran was noted to have some avoidance behaviors and occasional panic attacks. He was alert, dysthymic, cooperative, pleasant, and soft spoken with spontaneous and not-pressured speech. He denied any aggressive behavior and any thought of harm to self or others and denied any audio or visual hallucinations and delusions. No psychotic symptoms were reported. The Veteran was seen for 60 minutes of medication management and supportive psychotherapy in November 2009, at which time he reported that he had quit working in June 2009 due to plantar fasciitis and was having significant financial problems. The Veteran's wife accompanied him and brought in a power of attorney because of the Veteran's failing memory and judgment. His wife reported that he had become disoriented at home in October and she had found him lying on his back "apparently asleep" and he was disoriented when she awakened him (didn't know where he was or who his wife was). He had a low grade fever at the time and painful swelling in his testicles. He was determined to have a urinary tract infection and antibiotics were started. The Veteran reported that he was having "trouble getting the words out" and was forgetting people's names. He watched television or visited with friends or tinkered in the garage. He was still mowing his yard but had stopped being treasurer at his church, which he had been for the last 15 years, because he was "making too many mistakes in the books." He had also made serious mistakes with the family's banking account and reported occasionally getting "turned around," but was hesitant to say "getting lost." The examiner indicated that it appeared the Veteran was minimizing his symptoms. The Veteran reported that he had noticed an increased tremor and had become very restless and had to get up and move around. He also noticed his thinking was slow at times. The Veteran reported struggling with no longer being able to work, and indicated that he had worked since he was 13 years old and felt he should be doing something. He had started many projects, but could not stay focused and did not finish them. Mood was rated 2/5, energy was low, and the Veteran was sleeping 6 hours per night with multiple awakenings, though his wife indicated that he had told her he was only sleeping about 4 hours per night and had substantial difficulty returning to sleep. Appetite was somewhat low, as was interest, but there were no suicidal thoughts or history of attempts, no homicidal ideation, and no psychotic symptoms. The Veteran reported daily intrusive thoughts/memories, occasional nightmares, anxiety 7/10, some avoidance behaviors, and panic attacks two times a week. Mental status examination revealed that the Veteran was alert, oriented, and appropriately groomed with blunted affect, limited eye contact, limited spontaneous speech, which was very slow and soft, decreased psychomotor activity, no tremor, and goal-oriented thought processes. The examiner noted concern with the Veteran's recent change in mental status, the possibility of medical illness as etiology, and the possible development of dementia. A GAF score of 55 was assigned. See mental health attending note. The Veteran was referred for a psych consult in December 2009 for assessment of his current cognitive abilities given changes in his functional status over the year prior. He completed a 30 minute clinical interview/neurobehavioral status exam, which was followed by a two and one-half hour face-to-face neurocognitive test and computerized psychological assessment. Following this evaluation, the Veteran's wife was also interviewed for 20 minutes for collateral information, with the Veteran present. In pertinent part, they reported that in October 2009, the Veteran's wife had found him lying on the floor next to his chair in his underwear, behavior that was highly atypical. He was hard to arouse and disoriented to his surroundings/knowledge of his wife upon awakening. She took him to the emergency room where he was found to have a low grade fever, painful swelling of the testicles, and a urinary tract infection. His cognition remained clouded but slowly returned to his previous baseline. However, the Veteran believed that his memory had become progressively worse over the past two years. In particular, he had problems with prospective memory as he often forgot to complete various chores/tasks for his wife and church. People had told him he repeats himself or asks the same questions, but he does not remember doing so. The Veteran reported intermittent problems with word finding, but stated this was most notable when he becomes flustered. He described himself as easily distractible and did not feel as observant to his surroundings, which had led to two minor vehicle accidents in the past few months. The Veteran also related increasing problems with detailed words and felt he became more easily overwhelmed, especially in situations of problem solving. These problems contributed to the Veteran's decision to retire from his job earlier that year due to mistakes being made and complaints about the quality of his work. They had also caused him to step down as the sole treasurer at his church due to multiple financial/book-keeping mistakes. While the Veteran continued to help out with the church treasury, helpers double check his work and had taken over the detailed work. The Veteran indicated that he had been having a harder time expressing himself, especially when flustered, and also described increasing periods of "spacing out" in which he does not recall events during those times. However, he was unable to provide further clarification to the frequency or length of those episodes. The Veteran's wife corroborated with the Veteran's report and added the symptoms had intensified over the past eight months. She started one of the most drastic changes was his inability to stay focused to finish various tasks, such that he often has several unfinished chores at home. When he returns to the unfinished chore, he has difficulty determining what he should do. The Veteran's wife related that his mentality appeared clearest in the morning hours before 11am and that as the afternoon progresses, he tends to become more confused and irritable, especially around the early evening hours. Due to these changes, his wife had recently completed paperwork to become his power of attorney. The Veteran described his current mood as "okay" and felt his current medication regimen was helpful. He estimated sleeping 6-7 hours per night and denied any problems falling/maintaining sleep and nightmares. He described his symptoms as "bouts of depression" in which he becomes more withdrawn, irritable and wary of crowds. His wife related that he had always been nervous but his anxiety had notably become worse over the past 8-9 months. She denied any other recent personality changes. The Veteran arrived alone and on time to the correct location for his appointment; his wife arrived later while he was testing. The Veteran presented as a pleasant and easily engageable man who was believed to minimize a variety of symptoms. He was overweight and appeared his stated age with good hygiene and grooming. Eye contact and interpersonal skills were grossly intact. He was alert and oriented to person, place, time, and purpose of appointment. He had no problems comprehending basic conversation or task instruction. No expressive language problems were noted and speech was intact to rate, tone, volume and prosody. Mood was euthymic but with somewhat blunted affect. The Veteran denied current suicidal or homicidal ideation/intent and there was no overt evidence of formal thought disorder, hallucinations, or delusions during evaluation. Remote and recent memory appeared largely intact, insight and judgment appeared grossly intact, and the Veteran was able to fluidly initiate his attention to tests without impulsivity or perseveration. While he was overtly cooperative, there was evidence of fluctuating effort throughout testing that appeared related to cognitive fatigue. As such, while testing overall was considered accurate reflections of his current abilities, some caution should be used in interpreting the scores. The examiner determined after testing that the subjective cognitive complaints appeared related to the unidentified pathology on neuroimaging but confounded with his level of generalized psychological distress. The Veteran did not meet the diagnostic criteria for dementia or any other neurodegenerative disorder. A January 2010 mental health attending note reveals that the Veteran was seen for 60 minutes of medication management and supportive psychotherapy. He reported much of the same problems as he had in November 2009. The Veteran's mood was rated 3-4/5, energy was low, and he was sleeping 8 hours per night with about two awakenings and was able to return to sleep easily. His appetite was good but interest was low. He denied suicidal thoughts and history of attempts and also denied homicidal ideation. There were no psychotic symptoms. The Veteran reported daily intrusive thoughts/memories, nightmares one to two times a week, anxiety at 5/10, some avoidance behavior, especially of crowds, and panic attacks one to two times a week. Mental status examination revealed that he was appropriately groomed with constricted, but somewhat reactive, affect. Speech and psychomotor activity were normal, thought processes were goal-directed, and the Veteran was alert and oriented. A GAF score of 50 was assigned. The Veteran was seen for 60 minutes of medication management and supportive psychotherapy in March 2010. Many of the same findings as in November 2009 and January 2010 were made. In pertinent part, mental status examination revealed that the Veteran was appropriately groomed with broad and appropriate affect. Speech and psychomotor activity were normal, thought processes were goal-directed, and the Veteran was alert and oriented. A GAF score of 50 was assigned. See mental health attending note. On June 15, 2010, the Veteran reported mood at 3/5, low energy, sleeping 6-7 hours per night with occasional awakenings to urinate, good appetite and low interest. He denied suicidal thoughts and history of attempts and also denied homicidal ideation. There were no psychotic symptoms. The Veteran reported daily intrusive thoughts and memories, nightmares once a week, anxiety 6-7/10, some avoidance behaviors, especially avoidant of crowds, and occasional panic attacks. Mental status examination revealed that the Veteran was appropriately groomed with constricted affect. He appeared tired. Speech and psychomotor activity were normal, thought processes were goal-directed, and the Veteran was alert and oriented. A GAF score of 50 was assigned. See mental health attending note. The Veteran was seen for 60 minutes of medication management and supportive psychotherapy in October 2010. Many of the same findings as in previous notes were made. In pertinent part, the Veteran reported attending Pleasant Valley Baptist Church, which he had been attending for 30 years, and not being close to an older half-brother, who was his only living relative, and to whom he had never been close. The Veteran reported mood at 4/5, low energy, sleeping 6-7 hours per night with occasional awakenings to urinate, good appetite and low interest. He denied suicidal thoughts and history of attempts and also denied homicidal ideation. There were no psychotic symptoms. The Veteran reported daily intrusive thoughts and memories, nightmares most nights, anxiety 8/10, some avoidance behaviors, especially of crowds, and occasional panic attacks, but none in recent weeks. Mental status examination revealed that the Veteran was appropriately groomed with constricted affect. He appeared tired. Speech and psychomotor activity were normal, thought processes were goal-directed, and the Veteran was alert and oriented. A GAF score of 50 was assigned. See mental health attending note. The Veteran underwent a VA examination in February 2011, as instructed by the Board in its September 2010 remand. He was accompanied by his wife and his claims folder was reviewed. In pertinent part, the Veteran denied any adverse effects from his medication and indicated that one was helpful with sleep. He denied any changes in his psychological treatment following the December 2009 neuropsychological evaluation. The examiner reported on specific treatment records already discussed above. The Veteran noted two new traumatic events in the form of his parents in-law dying in January 2010 and October 2010. He indicated that he had known them for 38 years and their deaths increased his depression during an adjustment period. The Veteran reported that he had retired in 2009 after a six year employment at a manufacturing plant. He stated that his feet and knees gave out on him and he could not deal with people anymore. He had worked the day shift and had to listen to peoples' complaints as he repaired their machines, was stressed out all the time, and "had a fear of going to work." The Veteran stated that he never knew what mood his supervisor was in or what was going to come up, that sleepless nights affected his performance, and that he would call out occasionally for mental health issues. The Veteran reported that since coming home from Vietnam, he had poor tolerance for any conflict or negative interaction at work and would walk off the job, leading to numerous jobs over the years. The Veteran reported that he had been married for 38 years with two adult sons who were on their own and married, one with children. He reported that he sat around most of the time and did not have "the want to get up and do things." The Veteran indicated that his wife had learned to adapt and not complain about his lack of activity. His relationship with his wife and other family members was described as good and although he had a good relationship with his grandchildren (13 and 2), they get on his nerves and he was short-tempered with them. The Veteran's wife reported increased irritability. Church was also a source of support and the Veteran reported attending on a regular basis for the past 31 years. He had grown accustomed to and comfortable with the people and participated in men's workday at church, but denied other social contacts. He had been more active with helping the church treasury, but had stopped this due to difficulties with the tasks. The Veteran reported watching television and doing a little around the house, but finances prevented him from doing many projects. He met with his oldest son for dinner and got together with his younger son about once a week at his son's house to see the progress he was making on a remodel. The Veteran denied a history of assault or assaultive behaviors and a history of suicide attempts. Mental status examination revealed no impairment of thought process or communication. The Veteran denied delusions, hallucinations, and their persistence. He was casually dressed with adequate grooming. Mood was ok, affect was depressed, restricted and flat, and the Veteran made limited eye contact with eyes downcast most of the interview, though he was cooperative. The Veteran denied suicidal or homicidal thoughts, ideations or plans or intent and his ability to maintain minimal personal hygiene/other basic activities of daily living were intact. Although he was one hour off on time, orientation to person, place, date, situation and time was otherwise intact. Compared to his peers of the same age, the Veteran thought his memory was worse. His wife has to repeat things to him, he forgets to put out the trash and forgets what day of the week it is, and indicated that he had forgotten to complete tasks at work. He denied any obsessive or ritualistic behavior that interfered with routine activities and panic attacks. Rate and flow of speech were within normal limits and the Veteran rated his usual mood at 8/10, stating that he thought about things that happened in service, worried, felt guilty, worthlessness, and sad. He rated anxiety at 7/10, stating that he felt like he needed to do something but did not know what, worried about everything, was edgy and irritable once a week, and was tense and had muscle soreness. There was no significant impairment of impulse control notes. The Veteran reported that with medication, he got 6-7 hours of uninterrupted sleep but without medication, he was getting about 4-5 hours of restless sleep and was waking up very tired. He also had frequent waking at night, nightmares about once every two weeks, and night sweats, though medication had helped. The Veteran had low energy for normal tasks, no regular naps, and had to force himself to do things. Appetite was "so so" and the Veteran reported that he vomited frequently and had been diagnosed with GERD. Specific symptoms of PTSD mentioned by the Veteran included people commenting at work that he was depressed and negative, avoidance of anyone who is very sick or terminally ill because he lost a friend shortly after he arrived in Vietnam, trying to stay busy to avoid thinking about Vietnam, being uncomfortable in crowds, and having intrusive thoughts continuously throughout the day. Axis I diagnoses of chronic, moderate, PTSD and recurrent, moderate to severe, major depressive disorder without psychotic features were made and a GAF score of 50 was assigned. The examiner noted that the depression appeared to be secondary to his PTSD and was a significant aspect of his mental illness presentation. A March 2011 mental health outpatient treatment note reveals that the Veteran reported he was sleeping 7 hours, that his mood was 5/10, anxiety was 6/10, anger or irritability was 3/10, and that he was having panic attacks and trauma-related memories or nightmares a few times per month. Flashbacks or dissociative episodes were occurring a few times per week. A March 2011 mental health attending note reports that the Veteran was seen for 30 minutes of medication management and supportive psychotherapy, during which many of the findings made during previous treatment were noted. Mood was rated at 3-4/5, energy was low, the Veteran reported sleeping 7-8 hours per night, appetite was good, and interest was low. The Veteran denied suicidal thoughts and history of attempt and also denied homicidal ideation. There were no psychotic symptoms. He noted daily intrusive thoughts and memories and indicated that nightmares had reduced to once weekly. Anxiety was 5/10, panic attacks were occurring 1-2 times a month, and he had some avoidance behaviors, especially of crowds. Mental status examination revealed that the Veteran was appropriately groomed with constricted affect. He appeared tired but had normal speech and psychomotor activity, goal-directed thought processes, and was alert and oriented. A GAF score of 50 was assigned. A May 2013 private treatment record from D.P., M.S. documents the Veteran's history of low energy, difficulty concentrating, sleep disturbance, anxiety, irritability, depression, disorientation, flashbacks, nightmares, panic attacks, and occupational impairment. D.P. also noted the Veteran's work history, including three years manufacturing of aluminum; over seven years operating heavy construction equipment and driving dump trucks; two years working construction installing underground cables; for nine years he performed general maintenance at a prison; and his last job was performing maintenance on production machines. D.P. opined that it is at least as likely as not that the Veteran's PTSD prevented him from securing and following a substantially gainful occupation since at least June 2009 when he stopped working and reasonably as far back as 2006. 1. Period prior to October 7, 2009 The evidence of record dated prior to October 7, 2009 does not support the assignment of a rating in excess of 30 percent. The Veteran's subjective symptoms during this time frame consist primarily of depression; nightmares; flashbacks; feeling useless/worthless/hopeless; initial and middle insomnia; lack of motivation and difficulty concentrating; distractibility; low energy and interest; intrusive thoughts/memories; panic attacks; avoidant behavior; irritability/variable mood; lack of appetite; nervousness/anxiety; feelings of guilt; sleep disturbance/impairment; loss of temper; impairment of memory; and withdrawal. There was also objective evidence of impaired mood (somber, lethargic, depressed, dysthymic); impaired affect (flat, blunted, constricted); impaired speech (soft/low/slow, limited in spontaneity); decreased psychomotor activity; disturbance in concentration; and limited eye contact. This degree of symptomatology and severity most closely approximates the criteria for continued assignment of a 30 percent evaluation. The evidence of record dated prior to October 7, 2009, does not reveal that the Veteran had symptoms the same as or similar to those set forth in the criteria for a 50 percent evaluation: circumstantial, circumlocutory, or stereotyped speech; difficulty understanding complex commands; impaired judgment, impaired abstract thinking; and/or difficulty in establishing and maintaining effective work and social relationships. Rather, mental status examinations revealed that the Veteran seemed intelligent; that his speech was well understood; speech was occasionally spontaneous/not pressured, clear, fluent, with appropriate/intact volume, rate, tone and prosody; and that judgment and insight were described as fair and grossly intact. In addition, the SSA psychiatric review technique assessment conducted in September 2009 showed only moderate limitations in the Veteran's ability to understand and remember and to carry out detailed instructions, and in his ability to maintain attention and concentration for extended periods. The Board acknowledges that the evidence of record supports a finding that the Veteran left his job, in part, due to symptoms of PTSD. Moreover, the Board notes that D.P., M.S., indicated in his May 2013 opinion that the Veteran's PTSD prevented him from securing and following substantially gainful employment as far back as 2006. The fact remains, however, that the Veteran was able to work until mid-2009 and that he noted problems with his knees and feet and the drudgery of the job as contributing issues. In addition, the Veteran consistently reported that despite some periods of separation, he remained married to the woman he had married in 1972 and that he participated in church, to include serving as its treasurer for some time. In addition, the SSA psychiatric assessment conducted in September 2009 showed only mild difficulties in maintaining social functioning and only moderate limitations in the Veteran's ability to get along with coworkers or peers. As such, the evidence does not support a finding that he had difficulty in establishing and maintaining effective work and social relationships. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology including nightmares, flashbacks, mood swings, intrusive thoughts, feelings of isolation, and limited eye contact which are not specifically listed in the General Rating Formula for Mental Disorders. See Mauerhan, supra. However, these symptoms are fully contemplated in the assigned evaluation as being of more similarity to or associated with the 30 percent criteria. For example, nightmares cause chronic sleep disturbances, and a lack of eye contact is indicative of anxiety or suspiciousness. Such symptoms do not more nearly approximate an overall level of functioning warranting a rating in excess of 30 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with reduced reliability and productivity. The Board also acknowledges that prior to October 7, 2009, GAF scores ranging from 50, which represent serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job), to 65, which represent 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, has some meaningful interpersonal relationships, were assigned. The majority of the GAF scores assigned during this period, however, were 55, which represent 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). Thus, the Board finds that the Veteran's PTSD symptomatology does not result in occupational impairment with reduced reliability and productivity. The Board finds the Veteran's reports of symptoms competent, credible and probative, however, the evidence as a whole does not show that the overall level of impairment resulting from PTSD approximates the criteria for a higher rating. Accordingly, the Board finds that the Veteran is not entitled to an initial rating in excess of 30 percent. Moreover, the Board finds that, during such time period, the Veteran's PTSD symptomatology, described above, does not more nearly approximate a 70 or 100 percent rating. The Board notes that the Veteran has arguably evidenced loss of temper and difficulty adapting to stressful circumstances. In this regard, the Board notes that the Court of Appeals for the Federal Circuit (Federal Circuit) recently held in Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013) that "in the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." However, the evidence does not show that the Veteran has occupational and social impairment with deficiencies in most areas, or, total occupational and social impairment. In this regard, the evidence fails to demonstrate such symptomatology as suicidal ideation; obsessional rituals to the extent that they interfere with routine activities; near-continuous panic or depression; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene; inability to establish and maintain effective relationships; gross impairment in thought processes or communication; delusions or hallucinations; grossly inappropriate behavior; persistent danger of hearing self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives or own name. Again, while recognizing that these are examples of symptoms indicative of reduced reliability and productivity or with deficiencies in most areas, or, total occupational and social impairment, the Board finds that the symptoms and signs manifested by the Veteran are at most indicative of an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; there is no showing of similar signs or symptoms as those listed under the 70 or 100 percent evaluations. In this regard, the evidence as a whole, as discussed above, does not show that the criteria for a higher rating are approximated. As such, for the foregoing reasons, the Board finds that the Veteran is not entitled to an rating in excess of 30 percent for PTSD prior to October 7, 2009. 2. Period from October 7, 2009 The evidence of record dated from October 7, 2009 does not support the assignment of a rating in excess of 50 percent. The Veteran's subjective symptoms during this time frame remain largely unchanged and consist primarily of low mood; low energy; impaired sleep; intrusive thoughts/memories; nightmares; avoidant behaviors; panic attacks; low interest; anger/irritability; anxiety; flashbacks; and dissociative episodes. The Veteran competently and credibly testified as to sinking into worsening depression, which resulted in not feeling like doing anything, any feeling worthless and that life had little meaning. There was also objective evidence of impaired affect (constricted, depressed, restricted and flat); impaired mood (appeared tired; ok mood); limited eye contact; and difficulty adapting to stressful circumstances. In this regard, the Board finds that the symptomatology manifested and the severity thereof, to specifically include the Veteran's low energy, intrusive thoughts, avoidant behaviors, low interest, flashbacks, and dissociative episodes, and other symptomatology discussed immediately above are contemplated in his current 50 percent rating, and are substantially similar to the specifically listed exemplars under the 50 percent criteria, as they have been shown to produce greater difficulty with memory and cognitive functioning, and reflect disturbances of motivation and mood. The Board also reiterates the Federal Circuit's holding in Vazquez-Claudio, supra that "in the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." The evidence of record dated since October 7, 2009, does not reveal that the Veteran had suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; and neglect of personal appearance and hygiene. Rather, he was reported to be adequately and appropriately groomed and alert and oriented during mental status evaluations, and speech and psychomotor activity were normal and thought processes were goal-directed. In addition, there was no significant impairment of impulse control noted, though the Veteran testified to getting into an argument with his pastor's wife and having to apologize for disagreements he had had with people; while the Veteran testified to "lashing out" at his pastor, he has consistently denied a history of assault or assaultive behaviors. The Board acknowledges that the Veteran's wife described obsessive behaviors at night, such as checking the doors to make sure they were locked, at the time of the June 2010 hearing; however, the Veteran has not described any obsessive or ritualistic behavior and the circumstances as described by his wife do not appear to interfere with the Veteran's routine activities. Lastly, the Veteran consistently denied psychotic symptoms, any suicidal ideation/any intent to harm himself, and any intent to harm others. The evidence of record during this time frame also does not reveal that the Veteran had an inability to establish and maintain effective relationships. Importantly, he remained married to the same woman during this time period; he reported having good relationships with his sons, meeting the oldest for dinner and getting together with his younger son about once a week at his son's house to see the progress he was making on a remodel; he reported having a good relationship with his two grandchildren, though they get on his nerves and he was short-tempered with them; and he remained active in church, attending on a regular basis and participating in a men's workday. The Board also notes that the evidence of record reflects that the Veteran has additional symptomatology during this period including anhedonia, helplessness, hypervigilance, periods of "spacing out," nightmares, flashbacks, mood swings, and intrusive thoughts. See Mauerhan, supra. These symptoms are, as is discussed above, more similar in appearance and effect to the criteria for a 30 percent evaluation, and hence do not support assignment of an increased rating. Moreover, the Board finds that such symptoms do not result in an overall level of functioning warranting a rating in excess of 50 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with deficiencies in most areas or total occupational and social impairment. In this regard, the Board reiterates the February 2011 VA examination report which characterized the Veteran's PTSD as "moderate" and depressive disorder without psychotic features as "moderate to severe." The Board acknowledges that GAF scores of 50 were assigned during this time frame, which represent serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). The severity of the Veteran's overall disability, as represented by the subjective and objective findings as reported in the preceding paragraphs, does not more nearly approximate the criteria for assignment of a 70 percent rating at any time since October 7, 2009. The Board also reiterates that, when evaluating the level of disability from a mental disorder, the rating is to be assigned based on all the evidence of record that bears on occupational and social impairment. See 38 C.F.R. § 4.126(a). Thus, the Board finds that the Veteran's PTSD symptomatology does not result in occupational impairment with deficiencies in most areas. Furthermore, the Board finds the Veteran's reports of symptoms competent, credible and probative, however, the evidence as a whole does not show that the overall level of impairment resulting from PTSD approximates the criteria for a higher rating. Accordingly, the Board finds that the Veteran is not entitled to a disability rating in excess of 50 percent. Additionally, the Board finds that, during such time period, the Veteran's PTSD symptomatology, described above, does not more nearly approximate a 100 percent rating. Indeed, the evidence does not show that the Veteran has total occupational and social impairment. Specifically, the Veteran's PTSD is not manifested by gross impairment in thought processes or communication; delusions or hallucinations; grossly inappropriate behavior; persistent danger of hearing self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives or own name. Again, while recognizing that these are examples of symptoms indicative of total occupational and social impairment, the Board finds that the symptoms and signs manifested by the Veteran are at most indicative of reduced reliability and productivity. In summary, the evidence as a whole, as discussed above, does not show that the criteria for a higher rating are approximated. As such, for the foregoing reasons, the Board finds that the Veteran is not entitled to a rating in excess of 50 percent for PTSD from October 7, 2009. Extraschedular consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b) (2012). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). The Veteran's PTSD symptoms cause impairment in occupational and social functioning, but such impairment is contemplated by the rating criteria and the Board finds that the rating criteria reasonably describe the Veteran's disability. There are no signs or symptoms complained of which are not considered under the Scheudle, and hence the Schedular criteria are adequate. Therefore, referral for consideration of an extraschedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an initial rating in excess of 30 percent for PTSD prior to October 7, 2009, and in excess of 50 percent thereafter is denied. ______________________________________________ WILLIAM H. DONNELLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs