Citation Nr: 1327092 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 08-35 393 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Christopher Loiacono, Agent WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Henriquez, Counsel INTRODUCTION The Veteran served on active duty from October 1968 to October 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida that assigned an initial evaluation of 30 percent, effective December 18, 2007, for the Veteran's PTSD. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in April 2010. A transcript of the hearing is associated with the claims files. In June 2011 and April 2012, this case was remanded for additional evidentiary development. While the case was in remand status, the Veteran was provided a Statement of the Case on the issue of entitlement to a total rating based on unemployability due to service-connected disabilities. In the cover letter sent with the Statement of the Case, the Veteran was informed of the requirement that he submit a substantive appeal within a specified time in order to perfect his appeal. The issue was not thereafter addressed in any communication from the Veteran or his attorney. Therefore, the Board has concluded that the Veteran is not currently seeking appellate review with respect to the unemployability issue. The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. FINDING OF FACT The occupational and social impairment from the Veteran's PTSD has more nearly approximated reduced reliability and productivity than deficiencies in most areas throughout the period of this claim. CONCLUSION OF LAW The criteria for an initial rating of 50 percent for PTSD, but not more, have been met throughout the period of this claim. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided adequate VCAA notice in a January 2008 letter, prior to the March 2008 rating decision on appeal. The Board also finds the Veteran has been afforded adequate assistance in regard to the claim on appeal. VA obtained the service treatment records along with all other relevant medical treatment records identified by the Veteran. The Veteran was afforded a VA psychiatric examination in conjunction with his claim for service connection for PTSD in March 2008. In October 2010 and November 2011, the Veteran was afforded VA psychiatric examinations to determine the current degree of severity of his PTSD. Pursuant to the Board's most recent remand in April 2012, VA scheduled the Veteran for a VA examination on two separate occasions to determine the nature and extent of all impairment due to his service-connected psychiatric disability and to address the etiology of all other acquired psychiatric disorders present during the period of the claim. The Veteran failed to report for these examinations. The Veteran indicated in January 2013 that he went to the wrong VA medical center. Accordingly, the Veteran was rescheduled for another examination; however, the Veteran failed to report to the subsequently scheduled examination without explanation. Neither the Veteran nor his representative has indicated that the Veteran would appear if the examination were to be rescheduled once again. As a result of the Veteran's failure to cooperate, the Board must decide the claim without the benefit of the examination ordered by the Board. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board is satisfied that the AMC substantially complied with the development requested on remand. See Stegall v. West, 11 Vet. App. 268 (1998). Neither the Veteran nor his representative has identified any outstanding, existing evidence that could be obtained to substantiate the claim. The Board is also unaware of any such evidence. Accordingly, the Board concludes that VA has complied with its duty to assist the Veteran in the development of the facts pertinent to this claim. Legal Criteria Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. PTSD is evaluated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted for PTSD 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 in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. A maximum 100 percent evaluation is for application when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Factual Background In accordance with 38 C.F.R. §§ 4.1, 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability. A VA mental health consultation report in December 2007 notes that the Veteran was depressed, had difficulty sleeping and that he reported having nightmares once a week related to Vietnam. The Veteran was casually dressed with adequate grooming. He was alert and oriented times four. His thinking was clear and organized. His speech had a normal rate and volume. No psychomotor retardation or agitation was noted. He was polite and cooperative. He reported that he had suicidal thoughts in the past when he was living alone. Currently, he was living with his daughter and her family. He denied any past suicidal attempts. He denied homicidal or paranoid ideation except at times when he wondered if the FBI is tapping his telephone. He denied hallucinations. His insight and judgment were sufficient for informed consent. The diagnoses were PTSD by history and dysthymia. A VA mental health consultation report in January 2008 notes that the Veteran was depressed and that he complained of homicidal and suicidal thoughts without any action to carry them out. He reported that flashbacks can happen anywhere. He also noted that he experienced paranoid thoughts of people trying to kill him. The examiner noted that the Veteran had good eye contact. He was oriented to person, place, time and situation. His memory for life events was intact. No thought process abnormalities were noted. He denied suicidal ideation, intent or plan. He denied any intent to harm himself or others. He displayed paranoid ideation that someone would shoot him. He displayed a preoccupation or obsession that the doors are closed. No abnormalities of thought content were noted. There was no evidence of response to internal stimuli. His mood was nervous. His affect was anxious. He was able to understand problems and he was able to verbalize possible solutions to the problems. He was able to make informed decisions. The diagnoses were major depression, cocaine abuse and PTSD. The examiner assigned a global assessment of functioning (GAF) score of 55. A March 2008 VA psychiatric examination report notes that the Veteran had been retired since January 2004. He had been divorced twice. Currently, the Veteran lived with daughter and her family. He did not pursue any activities or leisure pursuits due to physical limitations. He denied a history of suicidal attempts. He denied a history of violence/assaultiveness. Due to medical and physical problems, he had no social activities or friends at the present time. The examiner noted that the Veteran was clean and casually dressed. His psychomotor activity and speech were unremarkable. He was cooperative and attentive toward to the examiner but was also tense and apprehensive at times. His mood was anxious and dysphoric. He was oriented to person, place and time. His thought process and thought content were unremarkable. The Veteran's sleep was helped by medication although he continued to have frequent nightmares of combat duty. There were no delusions. There was paranoid ideation. At times, he had paranoid feelings of people wanting to harm him. He was hyperalert with frequent checking of the perimeter and locks. He denied any hallucinations. He did not display any inappropriate behavior. He did not display any obsessive/ritualistic behavior. He did not have any panic attacks. There were no homicidal attacks. He did not have any homicidal thoughts. He did have suicidal thoughts which were described as episodic and less than in the past with no active ideations or plans at the present time. His impulse control was good. He did not have any episodes of violence. He was able to maintain minimum personal hygiene. He did not have any problems with activities of daily living. His immediate, recent and remote memory was good. The diagnosis was PTSD. The examiner assigned a GAF score of 55. The examiner noted that the Veteran's PTSD symptoms resulted in deficiencies in judgment, thinking, family relations and mood. A February 2009 VA psychiatry medication management note indicates that the Veteran denied suicidal or homicidal ideas at the present time but he admitted to random thoughts that no one needs him. He reported that he did not want to die. The Veteran was noted to be casually dressed and neatly groomed. His attention and concentration were fair. He had no abnormal movements. His mood and affect were "euthymic"/appropriate. His speech was goal directed and logical. His memory was intact. He denied suicidal or homicidal ideations or intent. His insight and judgment were fair. The diagnoses were PTSD and major depression. He was assigned a GAF score of 50. An August 2009 VA medication management note indicates that the Veteran reported having on and off passive suicidal thoughts. He continued to have flashbacks of the Vietnam War. His nightmares were less frequent. He reported that he hears voices. The examiner noted that the Veteran's appearance and eye contact were appropriate and that he was well groomed. His speech was pressured. His attitude and behavior were cooperative and calm. His mood was euthymic. His affect was mood congruent and range was normal. His thought processes were logical, coherent and goal directed. His thought content was appropriate. He denied suicidal and homicidal ideation. He reported having flashbacks. He was oriented to person, time, place and situation. His memory and concentration were intact to conversation. The diagnoses were PTSD and depression. A GAF score of 42 was assigned. In a subsequent August 2009 VA mental health suicide risk assessment note, it was reported that the Veteran had presented with suicidal ideation, threats or self-harm within the past 30 days. However, the Veteran clarified that he has no plan or intent to act on them and that they are passing thoughts. An October 2009 VA psychiatry note indicates that the Veteran complained of having nightmares and of waking up in a sweat. He reported that he has not had suicidal thoughts for some time. He continued to hear voices that he cannot make out but he hears them usually at night. The examiner noted that the Veteran was alert, cooperative, oriented and that his mood was okay. His affect was appropriate to mood. He is memory was intact. He denied delusions. He denied auditory, tactile, visual or olfactory hallucinations. He denied suicidal or homicidal ideations. The diagnoses were PTSD, depression, attention-deficit hyperactivity disorder (ADHD), cocaine abuse in remission, neuroleptic-induced Parkinson and R/O bipolar disorder. A GAF score of 44 was assigned. A November 2009 VA mental health note indicates that the Veteran was well-groomed and casually dressed for his first individual psychotherapy session. His mood and affect were mildly euthymic. His speech was goal-oriented, but easily derailed. He often stopped in the middle of a sentence, trying to remember what topic he was talking about. He was alert, amiable and cooperative throughout the session. There were no current indications of suicidal or homicidal ideation or evidence of hallucinations and/or delusional material. His intelligence, judgment and insight were all seen as adequate for psychotherapy, although memory and concentration were significantly impaired. The diagnoses were PTSD and depression. A GAF score of 50 was assigned. A February 2010 VA mental health note indicates that the Veteran was alert and oriented to person, place, time and situation. He was cooperative throughout the session. There were no current indications of suicidal or homicidal ideation or evidence of hallucinations and/or delusional material. These symptoms were, in fact, denied. Intelligence, memory, judgment and insight were all seen as adequate for psychotherapy and sufficient for informed consent. The diagnoses were PTSD and related symptoms, major depression, cocaine abuse in remission, ADHD and rule out organic brain syndrome (OBS). A GAF score of 45 was assigned. The Veteran testified at an April 2010 Board hearing that he experiences memory loss, flashbacks, nightmares and auditory hallucinations. He also reported that he has panic attacks and suicidal ideation. In an April 2010 statement, the Veteran's daughter reported that she has witnessed an increase in his PTSD and depression/manic episodes. She reported that he spends the majority of his time at home watching television. In particular, she noticed that his ability to remember short-term items had been affected. She felt that he became disoriented when discussing items and was very random in his thoughts. A May 2010 VA mental health evaluation note indicates that the Veteran reported a chronic history of intermittent flashbacks. The examiner noted that his grooming and hygiene were appropriate and that he was appropriately dressed for the weather. His motor activity was relaxed. His speech had a normal rate/volume. His mood was calm and his affect was broad. His orientation was normal. His attention was normal. His concentration and memory were normal. His thought process was normal and linear and goal oriented. There were no hallucinations. His impulse control was fair. The diagnoses were dysthymia, PTSD and ADHD. A GAF score of 48 was assigned. During a private psychiatric evaluation in July 2010, the Veteran complained of having a depressed mood, feeling anxious and feeling like he has no energy to go anywhere. He did not want to get out of the house and spend time with other people. He complained of a certain degree of hopelessness and helplessness and that he has had fleeting suicidal thoughts but he denied any plans or intent at this point. He denied any homicidal thoughts. His main concerns were his anxiety, poor concentration and irritability. He was also having problems with his sleep and flashbacks. The Veteran described his mood as "not too bad." The examination disclosed that his affect was calm at times and sometimes anxious. At times he had a very labile affect. His thought processes were at times goal directed and at times very tangential with prominent pauses and losing track of his thought process. He did not appear to be delusional. He denied auditory or visual hallucinations. He was not suicidal or homicidal. The diagnoses were PTSD, bipolar disorder, cognitive disorder and rule out dementia. The examiner assigned a current and past year GAF score of 45. The examiner concluded that the Veteran had total occupational and social impairment due to persistent inappropriate behavior, intermittent ability to perform activities of daily living, and on and off disorientation to time and place and memory loss. An October 2010 VA psychiatric examination revealed that the Veteran reported that his main concern was his concentration decline. He reported that his mood varied and he may feel depressed about three days a month. The examiner found it difficult to get specific detailed history from the Veteran due to his attention-concentration problems. He currently lived alone. He stated that he watched television, fed his cats and used the computer. He denied a history of suicide attempts. He denied a history of violence/assaultiveness. The examiner noted that the Veteran was casually dressed. His speech was spontaneous. His attitude toward the examiner was cooperative and friendly. He laughed a lot. He tended to lose track of what he was thinking and seemed scattered and distracted midstream in conversation. He was intact to person and place but not to time. His thought process was circumstantial. He did not have consistently goal-directed thought processes as he would stop and not complete a thought and ask the examiner what the question was. His thought content was unremarkable. He did not have any delusions. He did not have persistent auditory hallucinations. He did not display any inappropriate behavior or obsessive/ritualistic behavior. He did not have any panic attacks. There was no presence of homicidal thoughts. There was presence of suicidal thoughts but he talked himself out of it because he wanted to see his family. His impulse control was fair. He denied any episodes of violence. He was able to maintain minimum personal hygiene. He did not have any problems with activities of daily living. His recent memory was moderately impaired and his immediate memory was mildly impaired. He had difficulty falling asleep and was hypergivilant. The examiner felt that the Veteran did not currently meet the criteria for a diagnosis PTSD. The Veteran was diagnosed as having cognitive disorder. The examiner could not offer a GAF for the PTSD since he did not meet the full criteria for PTSD on the current examination. The examiner felt that the Veteran's main problem was his cognitive functioning and this was unrelated to his PTSD. However, the examiner stated that this needed to be clarified with neurology and neuropsychology which was out of scope to the examiner as testing materials were not available at the present time. VA mental health treatment records dated in March 2011 document the Veteran's ongoing difficulty in talking about past drama and/or current dysfunction in a logical and consistent fashion. He also reported passive suicidal thoughts with no specific plan. He presented in casual attire and his hygiene was noted to be fair. The diagnoses were PTSD, mood disorder and ADD. A GAF score of 49 was assigned. The Veteran was provided a VA examination in November 2011 and the examiner prepared an addendum to the examination report in December 2011. The examiner noted that the Veteran's current symptoms were impairment of short-and long-term memory and circumstantial, circumlocutory or stereotypes speech. The Veteran was casually dressed. His psychomotor activity was unremarkable. His speech was spontaneous and clear. His attitude was cooperative and friendly. He frequently laughed. His mood was good. He was intact to person, time and place. He frequently lost his train of thought. His thought content was unremarkable. He did not have any delusions. He did not have persistent auditory hallucinations. He did not display any inappropriate behavior or obsessive/ritualistic behavior. He did not have any panic attacks. He had not homicidal thoughts. He did have suicidal thoughts but he talked himself out of it because he wanted to see his family. His impulse control was fair. He denied any episodes of violence. He was able to maintain minimal personal hygiene. His recent memory was moderately impaired and his immediate memory was mildly impaired. The diagnosis was cognitive disorder. The examiner could not offer a GAF score for PTSD since the full criteria for a diagnosis of PTSD were not found on examination. The examiner reported that the main problem was his cognitive functioning which was unrelated to PTSD. The examiner felt that this needed to be clarified with neurology and neuropsychology and was out of scope of the examiner's ability as the materials were not provided. The record does not reflect that further clarification was obtained from neurology or neuropsychology. VA psychiatry notes dated in October 2012 and February 2013 document the Veteran's complaints of chronic PTSD with nightmares, flashbacks and hyerpvigilence. The Veteran was noted to be appropriately dressed. His concentration was brief. His memory was normal. He did not display any auditory or visual hallucinations. There was no delusional thought. The diagnoses were PTSD, mood disorder NOS, and ADHD. GAF scores of 50 were assigned. As noted above, the Veteran failed to cooperate with VA's efforts to afford him another VA examination to determine the nature and extent of all impairment due to his service-connected psychiatric disability and to address the etiology of all other acquired psychiatric disorders present during the period of the claim. Analysis The Board finds based on the totality of the evidence and after resolving reasonable doubt in favor of the Veteran, that the impairment from his PTSD more nearly approximates the criteria for a 50 percent rating than the criteria for a 30 percent rating. The Board acknowledges that the medical evidence of record does not reflect that the Veteran experiences all of the symptoms associated with the 50 percent schedular rating. Yet the record does show that he has occupational and social impairment with reduced reliability and productivity due to such symptoms as: constricted affect; memory problems; disturbances of motivation and mood; attention and concentration slightly affected; some difficulty in maintaining focus in conversations; and difficulty in establishing social relationships. He does not have circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; or impaired judgment. However, the Court has held that the symptoms enumerated under the schedule for rating 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the preponderance of the evidence establishes that throughout the initial rating period, the social and occupational impairment from the disability has not more nearly approximated the deficiencies in most areas required for a 70 percent rating. In evaluating a psychiatric disability, the Board is mindful that when it is not possible to separate the effects of service-connected and non-service-connected disabilities, such effects should be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). The Board has done so in this case but points out that none of the Veteran's impairment was attributed to PTSD in the December 2007 VA mental health consultation report, the October 2010 VA examination report, the November 2011 VA examination report or the December 2011 addendum to the November 2011 examination report. To this point, specific symptoms associated with the 70 percent rating include suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. During the entire period, there is no showing that the Veteran had gross impairment of thought processes or communication, persistent delusions, exhibited grossly inappropriate behavior; persistent danger of hurting himself or others or intermittent inability to perform activities of daily living. While the Board acknowledges that the Veteran has reported episodic suicidal ideation, he has not demonstrated any plan or intent. Moreover, while the October 2010 examination report notes that the Veteran was not oriented to time, previous and subsequent clinical records indicate that he was oriented to person, time and place. The Board further notes that while the private July 2010 examiner concluded that the Veteran exhibited total occupational and social impairment, the reported symptomatology during the examination does not support such a conclusion. In particular, it was noted that the Veteran was not delusional. He denied auditory or visual hallucinations. He was not suicidal or homicidal and his mood was described as "not bad." The evidence also indicates that the Veteran has maintained a relationship with his daughter and her family. In evaluating the evidence, the Board has considered the various GAF)scores that clinicians have assigned. The GAF score is based on a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 61-70 reflects some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51-60 indicates 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 score of 41-50 reflects 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). A GAF score of 31-40 reveals 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). DSM-IV at 46-47. The GAF scores of record range from 42 to 55, which show moderate to serious impairment. A schedular rating of 70 percent rating is awarded for occupational and social impairment with deficiencies in most areas, but the evidence of record does not show the Veteran's PTSD more nearly approximates such impairment. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted more than 50 percent. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). VA must also consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in arriving at the determination above the Board has considered the statements of the Veteran and his daughter. Although the Veteran is competent to describe his symptoms and his daughter is competent to report her personal observations, and in affording those statements full credibility, they do not show that his occupational and social impairment has more closely approximate the schedular criteria for the next higher evaluation of 70 percent. The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The Court has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the manifestations of the disability and the impairment from the disability are consistent with the schedular criteria. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the increased rating granted herein. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a 50 percent rating, but not higher, for PTSD is granted, subject to the criteria applicable to the payment of monetary benefits. ___________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs