Citation Nr: 1325633 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 09-45 325 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to April 1, 2013. 2. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) from April 1, 2013. REPRESENTATION Appellant represented by: John R. Worman, Attorney at Law ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The Veteran served on active duty from April 2002 to September 2007. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the St. Petersburg, Florida RO, which continued the initial 30 percent rating assigned for PTSD. A January 2012 rating decision granted an initial rating of 50 percent for PTSD, effective since separation. In August 2012, the Board remanded the matter for additional development. A May 2013 rating decision increased the rating for PTSD from 50 percent to 70 percent effective April 1, 2013 (the date of a private evaluation showing that the criteria for a 70 percent rating were met); that rating decision also granted the Veteran a total disability rating based on individual unemployability due to service-connected disability (TDIU), thus resolving the matter previously before the Board. FINDINGS OF FACT 1. Prior to April 1, 2013, the Veteran's service-connected PTSD was not manifested by 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 work like setting); inability to establish and maintain effective relationships. 2. From April 1, 2013 to the present, the Veteran's PTSD is not shown to be manifested by 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. CONCLUSIONS OF LAW 1. Prior to April 1, 2013, the criteria for entitlement to a disability evaluation in excess of 50 percent for the Veteran's service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.130, Diagnostic Code (Code) 9411 (2012). 2. From April 1, 2013, the criteria for entitlement to a disability evaluation in excess of 70 percent for the Veteran's service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.130, Diagnostic Code (Code) 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) Veteran status; 2) existence of a disability; (3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant with notice in September 2007 and July 2008, prior to the initial adjudication, and February 2009 after the initial adjudication. While the complete notice was not provided prior to the initial adjudication, the claimant has had the opportunity to submit additional argument and evidence, and to participate meaningfully in the adjudication process. The claim was subsequently readjudicated in numerous supplemental statements of the case, most recently in May 2013, following the provision of notice. The appellant has not alleged any prejudice as a result of the untimely notification, nor has any been shown. As the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award for PTSD, statutory notice had served its purpose, and its application was no longer required. See Dingess, supra, aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). A September 2009 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased rating; while a May 2013 supplemental SOC (SSOC) readjudicated the matter after the appellant and his attorney responded and further development was completed. 38 U.S.C.A. § 7105. The Veteran has had ample opportunity to respond/supplement the record. He has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (holding that "where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield, supra. Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist VA has obtained service treatment records; assisted the appellant in obtaining evidence; afforded the Veteran VA examinations in February 2008, November 2011, and January 2013; obtained medical opinions as to the etiology and severity of disabilities; and afforded the appellant the opportunity to give testimony before the Board. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file, and the appellant has not contended otherwise. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file (including via Virtual VA), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence. See Gonzales v. West, 218 F, 3d, 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the evidence as appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claim. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected PTSD has been rated by the RO under the provisions of Diagnostic Code 9411. Under this regulatory provision, a 50 percent rating is warranted if the Veteran experiences 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 in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted if the Veteran experiences occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of closest relatives, own occupation, or own name. The Veteran has been assigned various Global Assessment of Functioning (GAF) scores for his PTSD. 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). Scores ranging from 31 to 40 reflect 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 other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Lesser scores reflect increasing severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes]. The Board recognizes that the Court in Mauerhan v. Principi, 16 Vet. App. 436 (2002), stated that the symptoms listed in VA's general rating formula for mental disorders is 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. However, the Court further indicated that without those examples, differentiating a 30 percent evaluation from a 50 percent evaluation would be extremely ambiguous. Id. at 442. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Prior to April 1, 2013 The Veteran's PTSD has been rated 50 percent disabling during this time period. The Veteran underwent a VA examination in February 2008. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that he was diagnosed with ADHD, inattentive type, as a child, and he was treated by a psychiatrist with prescription medications. He reported that he was living with his parents and had a good relationship with them. He had several soldiers he kept in touch with, and he talked to friends on the phone and visited with others when he could. He talked with his boss, who was also a veteran. He had limited social interactions because he worked full time in 12 hour shifts, 4 to 6 days per week. He reported doing "nothing" for fun. He denied any history of suicide attempts or violence or assaultiveness. He reported good support from his family and limited social interactions due to working a lot. On examination, the Veteran was clean, neatly groomed, and appropriately and casually dressed. His psychomotor activity and speech were unremarkable. His attitude was cooperative, friendly, and attentive. His affect was constricted and his mood was agitated. His attention was intact, and he was oriented to person, time, and place. His thought process and thought content were unremarkable. He showed no signs of delusions and understood the outcome of his behavior. His insight was intact in that he understood that he had a problem. He reported difficulty falling and staying asleep. He denied any hallucinations. He showed no inappropriate behavior and denied any obsessive or ritualistic behavior. He denied any panic attacks, homicidal thoughts, or suicidal thoughts. His impulse control was good and he denied any episodes of violence. His remote, recent, and immediate memory was normal. He denied any problems with activities of daily living. He reported chronic symptoms of daily recurrent/intrusive recollections, distressing dreams almost every night, reliving his stressor events almost every day, psychological distress at exposure that never went away, physiological reactivity on exposure almost daily, avoidance of the beach or sand, diminished interest, feeling detached and unable to relate to people, a restricted range of affect, a sense of a foreshortened future, nightly difficulty with sleep, daily irritability or anger, occasional difficulty concentrating, and constant hypervigilance. The examiner opined that the severity of the symptoms reported was moderate. The diagnosis was chronic PTSD, and the examiner assigned a GAF score of 60, opining that there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning. The Veteran submitted two VA medical opinion letters, dated June 2008 and July 2008, noting that he was being treated in the PTSD clinic for moderate to severe symptoms of PTSD. The Veteran had recently begun developing a major depression with associated panic attacks, agoraphobia, and stuttering in public settings. He was aggressively seeking and working on the issues in treatment, but his reactions to the severe prolonged combat stressors were significantly interfering with his current everyday functioning. The treating psychologist and psychiatrist opined that it would place undue harm on the Veteran to engage in his expected National Guard duties at that time due to worsening depressive and anxiety symptoms. On an April 2011 Mental Residual Functional Capacity Questionnaire, the diagnosis was PTSD, and the private psychiatrist Dr. Fennell assigned a GAF score of 55. The Veteran reported extreme anxiety and anger as well as poor concentration, severe depression, and nightmares, on mental status examination. Dr. Fennell opined that the Veteran had severe PTSD which caused inability to function in work-related activities on a day to day basis in a regular work setting. The Veteran underwent a VA examination in November 2011. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that he had lived with his parents since separation from service. He had been engaged twice yet both engagements ended due to distance, stress issues, and incompatibility. He reported that his mood went up and down. He reported having no friends and stated that he had been extremely isolated for the previous two years, noting that he did not leave the house for several weeks at a time. In general, he reported that he got along with others. He reported having difficulty driving with other cars around him. He reported having no hobbies or enjoyable activities, although he took his service dog out when necessary. He reported having elevated anxiety when out in public. He was unemployed since being fired from his last job in security in 2009. He was undergoing PTSD individual therapy treatment which included psychotropic medications. He reported having a hard time backing off from confrontation but denied a history of getting into fights. He reported a passive suicidal ideation yet denied any plan, intention, or history of suicidal gestures. On examination, the Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss such as forgetting names, directions or recent events, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, and inability to establish and maintain effective relationships. The examiner noted that the degree of psychopathology the Veteran reported experiencing upon MMPI-2 testing was unusual even in a clinical population; the examiner noted that it may be that the results represent a cry for help, but it is quite likely that there was some intentional exaggeration of the current symptom picture, especially in the context of external gain (i.e. disability benefits). The examiner opined that the test results are invalid and uninterpretable. The diagnosis was chronic PTSD, and the examiner assigned a GAF score of 50. The examiner opined that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. The examiner opined that the Veteran was employable by mental health standards alone. The Veteran submitted two private evaluations administrated in June 2012. Dr. Fink noted that the Veteran's attempts at employment after service were met with difficulty resulting from his inability to deal with the fact that he was easily frustrated and angered, argumentative, had concentration problems, and episodes of extreme anxiety and depressiveness. His dominant symptoms were noted to include intrusive thoughts and memories of the stressor events, recurrent nightmares, hypervigilance, exaggerated startle response, hyperarousal, mood lability, irritability and outbursts of anger, social anxiety with isolating and avoidance behaviors, emotional distancing, difficulty concentrating, and anhedonia. Dr. Fink assigned a GAF score of 50, reflecting serious symptoms or any serious impairment in social, occupational, or school functioning. Dr. Fink opined that the Veteran's PTSD results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. In a separate vocational opinion, Dr. Barnes noted based on a review of the medical records, including the mental status examination conducted by telephone by Dr. Fink, that the Veteran had difficulty getting along with others in the workplace, maintaining focus and concentration, and had issues with mood stability. Dr. Barnes noted that the Veteran's symptoms had been documented as flashbacks, social isolation, depression, anxiety, nightmares, sleep disturbances, memory issues, concentration disruptions, irritability and intrusive thoughts. Dr. Barnes noted the GAF scores of 50 assigned on November 2011 VA examination and by Dr. Fink in June 2012. Dr. Barnes opined that the Veteran's most significant impairment appeared to arise from the impact of his PTSD; she opined based on a review of the medical records that the Veteran could not work in a competitive setting, and he was totally and permanently precluded from performing work at a substantial gainful activity level due ot the severity of his service connected impairments impacting his emotional stability in the workplace. The Veteran underwent a VA examination in January 2013, pursuant to the Board's August 2012 remand. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that he had a "touch and go" relationship with his brother; they did not interact despite living 25 minutes apart. He reported that he lived with his parents because he did not have the money to live on his own; he described the relationship with his parents as good. He reported having one best friend he had known since he was 10, although they did not get to interact as often as he would like due to the friend's own job; he also spent time with his friend's brother and parents. He reported being extremely isolated, and he did not leave the house for weeks at a time. He reported that he went shooting with a group of combat veterans. His main hobbies were gardening and welding, which he would do for hours, as long as his body could stand it; he also enjoyed studying languages every day. He reported that his medications flattened his energy. He reported having recurring nightmares and intrusive thoughts. His symptoms were noted to include depressed mood, anxiety, chronic sleep impairment, nightmares once to twice per week, daily intrusive recollections, daily psychological distress and physiological reactivity, avoidance of thoughts and conversations several times a week, avoidance of people and places almost daily, restricted range of affect much of the time, daily difficulty with falling and staying asleep, problems with concentration, hypervigilance, and infrequent exaggerated startle response. On examination, the Veteran was cooperative and his speech was normal in rate and tone. His thought content and progression was within normal limits. Hallucinations and delusions were not present, and there was no grossly inappropriate behavior. His attention and concentration were within normal limits. His memory was within normal limits. His insight and judgment were fair, and his abstract reasoning was within normal limits. He denied any suicidal or homicidal ideation. The diagnosis was PTSD, and the examiner assigned a GAF score of 63, noting that the GAF score was speculative and conservative due to the results of objective testing. The examiner noted that GAF scores assigned by mental health treatment providers were inapplicable to the current exam because they had been based predominantly on the Veteran's subjective report without an objective assessment of response style. The examiner opined that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner opined that there were no psychological reasons the Veteran should not be able to obtain or maintain employment; given his reports of not liking being around a number of people and preferring to limit social interactions, there were a number of jobs he would be best suited for including gardener, woodworker, bookkeeper, accounting, medical records and health information technician, graphic design, paralegal studies, information security analyst, medical laboratory technician, software engineer, and technical writer, among others. The Veteran underwent several outpatient examinations in which his symptoms were similar in type and in degree to those demonstrated on the February 2008, November 2011, and January 2013 examinations. He was assigned a GAF score of 60 in April 2008, June 2008, and July 2008. He was assigned GAF scores of 50, 48, 55, 58, and 52 in July 2008, November 2008, November 2009, April 2010, April 2011, June 2011, July 2011, June 2012, December 2012, and March 2013. Social Security Administration (SSA) records reflect that the Veteran was found to be disabled from December 5, 2009 due to a history of traumatic brain injury, major depressive disorder, and PTSD. In addition to the medical evidence, the Veteran has submitted several lay statements regarding the nature of his symptoms. For example, an August 2008 statement from his parents stated that his symptoms had increased significantly in the previous six months and he had not been able to perform ordinary daily living activities due to increasing anxiety, panic attacks, paranoia, and suicidal and homicidal thoughts. The Veteran's parents noted that he had become incapable of employment following stressful work experiences such as forceful confrontations, and he was being considered for medical discharge from his National Guard unit due to physical and mental disorders. The Board finds all the lay evidence to be both competent and credible. However, based on the overall evidence, the Board finds that a rating in excess of 50 percent is not warranted prior to April 1, 2013. There is no doubt that the Veteran's disability caused some occupational and social impairment. However, he kept a healthy relationship with his parents, with whom he lived. As such, he was able to establish and maintain effective relationships. There does not appear to have been any deficiencies in the Veteran's judgment or thinking. For the most part, the Veteran did not exhibit suicidal ideation or obsessional rituals. The Board finds that prior to April 1, 2013, the Veteran's PTSD did not cause occupational and social impairment with deficiencies in most area, 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 work like setting); and inability to establish and maintain effective relationships. From April 1, 2013 The Veteran underwent a private evaluation by Dr. Henderson-Galligan on April 1, 2013. He reported that he was terminated from his last job doing security due to fighting with clients; he was later rehired but was not successful due to his PTSD symptoms worsening. He reported that the work triggered panic attacks. Dr. Henderson-Galligan noted that the Veteran's symptoms throughout the VA treatment records included experiencing or witnessing events involving actual or threatened death, serious injury, or threat to physical integrity of self or others; communicating a response involving intense fear, helplessness or horror while deployed; recurrent and distressing recollections, images, thoughts or perceptions of events while deployed; recurrent nightmares of deployment events; occasional experiences, illusions, hallucinations, dissociative flashbacks of reliving deployment events; psychological distress; physiological reaction; avoidance of thoughts, feelings, conversations associated with the stressor events; avoiding activities, places, or people that manifested recollection of the events; inability to recall important aspects of the traumatic events; diminished interest in participation; detachment and estrangement from others; restricted range of affect and affection; sense of foreshortened future; persistent sleep disturbance; chronic irritability and anger; concentration difficulties; hypervigilance; and exaggerated startle response. Dr. Henderson-Galligan opined that the symptoms caused clinically significant distress in social, occupational, and other areas of daily functioning. On examination, the Veteran's attention was normal and his concentration appeared variable. He complained of increased trouble with short-term memory and was forgetful about remembering basic information. His speech flow was normal, his thought content was appropriate, and his organization of thought was goal directed. There was no report of overt hallucination. His intellectual abilities and capacity for abstraction appeared normal. His judgment was somewhat bizarre. His mood was anxious and nervous, and his affect was restricted. He endorsed symptoms of a major depressive disorder and panic disorder with agoraphobia. He reported suicidal ideation but denied any intent or plan. He denied overt hallucination but stated that he had difficulty distinguishing hallucination from PTSD symptomatology. He continued to live with his parents but also continued to socially isolate and ruminate over security and safety, often rechecking doors and windows. He was not able to attend to his hygiene on a daily basis and did not eat with regularity. He had difficulty interacting with most people and felt as if he even isolated from his family members. He reported that he did not have any same age peers, and he had become reclusive due to the PTSD symptoms, depression, and agoraphobia, and he could not emotionally or physically leave the house without a violent reaction. The diagnoses included chronic PTSD, major depressive disorder, and panic disorder with agoraphobia. A GAF score of 50 was assigned to reflect serious symptoms. Dr. Henderson-Galligan opined that the Veteran may better be classified as 70 percent impaired due to his occupational and social impairment with deficiencies in most areas; she opined that the Veteran was unemployable as he could not sustain the stress from a competitive work environment and could not be expected to engage in gainful activity secondary to his severe level of impairment. VA treatment records from April 2013 reflect symptomatology largely similar to the April 2013 private evaluation above. The Veteran's PTSD has been rated 70 percent disabling effective April 1, 2013. The only rating in excess of 70 percent under Diagnostic Code 9411 is a 100 percent rating. In order to warrant a 100 percent rating, the Veteran's disability must be manifested by 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The Board finds that a rating in excess of 70 percent is not warranted for the period from April 1, 2013. The Veteran displayed few (if any) of the types of symptoms enumerated in the 100 percent rating criteria. His disability was not manifested by gross impairment thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The Board acknowledges that the Veteran's PTSD impairment has been undoubtedly quite significant throughout the relevant period. However, the totality of the evidence does not show total occupational and social impairment due to the types of symptoms set forth as examples under the criteria for a 100 percent schedular rating. The evidence shows that although his social life was impaired, he still maintained relationships with his parents. Additionally, his thought content was appropriate, and his organization of thought was goal directed. The Board is unable to find that the disability picture has shown total impairment at any time as required by the diagnostic criteria. The potential application of various provisions of Title 38 of the Code of Federal Regulations has also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards". 38 C.F.R. § 3.321(b)(1). Rather, as discussed above, the evidentiary record in this case persuasively shows that the Veteran's PTSD symptoms squarely match the type and degree of the examples set forth under the criteria for the current 50 and 70 percent schedular rating. Consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is not appropriate in such a case where the rating criteria reasonably describe the Veteran's disability level and symptomatology. See generally Thun v. Peake, 22 Vet. App. 111 (2008). The Board therefore finds that referral for extraschedular consideration under 38 C.F.R. § 3.321(b)(1) is not warranted in this case. ORDER Entitlement to a rating in excess of 50 percent for PTSD prior to April 1, 2013, is not warranted. Entitlement to a rating in excess of 70 percent for PTSD from April 1, 2013, is not warranted. The appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs