Citation Nr: 1327319 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 07-05 359 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to an initial disability rating for service-connected posttraumatic stress disorder (PTSD), in excess of 30 percent from August 27, 2004, and 50 percent from July 8, 2008. REPRESENTATION Veteran represented by: California Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Veteran and S.Y. ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from October 1967 to October 1970. Service in the Republic of Vietnam is indicated by the record. The Veteran is the recipient of the Purple Heart Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which granted service connection for PTSD and assigned a 30 percent disability rating from August 27, 2004. In a supplemental statement of the case (SSOC), the RO increased the disability rating assigned to the service-connected PTSD to 50 percent, effective July 8, 2008. The Veteran has not expressed satisfaction with the increased disability rating. This case thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). In September 2012, the Veteran presented sworn testimony during a personal hearing in Los Angeles, California, which was chaired by the undersigned. A transcript of the hearing has been associated with the Veteran's VA claims file. Relevant to this proceeding, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the individual who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the undersigned noted the basis of the prior determination and noted the elements that were lacking to substantiate the claim for benefits. In addition, the undersigned sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), or otherwise identified any prejudice in the conduct of the hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. In a January 2013 Board decision, the claim was remanded for further evidentiary development. As will be discussed below, review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The VA Appeals Management Center (AMC) continued the previous denial in an April 2013 SSOC. The Veteran's VA claims file has been returned to the Board for further appellate proceedings. FINDING OF FACT The Veteran's PTSD for the entire period involved in this claim is shown to be productive of occupational and social impairment with reduced reliability and productivity, but not by total occupational and social impairment, or by occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial disability rating of 50 percent, but no higher, for the service-connected PTSD have been met since August 27, 2004. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The criteria for the assignment of a disability rating in excess of 50 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.13, 4.130, DC 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.129(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that claimant is expected to provide. Here, however, the Veteran's claim for an increased initial rating for his service-connected PTSD is a "downstream" issue in that it arose from an initial grant of service connection for this disability. Prior to the April 2005 rating decision, the RO issued a letter in November 2004 that advised the Veteran of the evidence necessary to substantiate his claim for service connection for this disability and of his and VA's respective obligations with regard to obtaining evidence. As previously noted herein, in the April 2005 rating action, the RO granted service connection for PTSD and evaluated this disability as 30 percent, from August 27, 2004, the date of claim. As indicated above, in a SSOC dated September 2008, the RO increased the disability rating assigned to the service-connected PTSD to 50 percent, effective July 8, 2008. Importantly, where, as here, service connection has been granted and the initial rating and effective date have been assigned, the claim of service connection 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 was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473,490-491 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Also, the agency of original jurisdiction (AOJ) obtained the Veteran's available service treatment records (STRs) and post-service treatment records, and secured three examinations in furtherance of his claim. Pursuant to the January 2013 Board Remand, the AMC requested the Veteran's records from the Social Security Administration (SSA) with respect to his claim for disability benefits. However, the AMC received a negative response from the SSA dated in February 2013. Specifically, the SSA indicated that said records could not be provided as "[t]here are no medical records. The person did not file for disability benefits. Or, the person filed for disability benefits, but no medical records were obtained." Thus, the Board finds that the AMC did comply with the Remand instructions in that the SSA records were requested, although a search determined that no such records existed. Accordingly, the Board finds that the Veteran has not identified any additional pertinent medical records that have not been obtained and associated with the claims file, to the extent available. 38 C.F.R. § 3.159(c)(1)-(3). VA examinations with respect to the PTSD claim on appeal were obtained in December 2004, July 2008, and February 2013. See 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained here are sufficient, as they considered all of the pertinent evidence of record, including the statements of the Veteran, and provided explanations for the opinions stated as well as the medical information necessary to apply the appropriate rating criteria. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome here, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Accordingly, VA has no duty to inform or to assist that has been unmet. II. Analysis-Schedular Evaluation Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating 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. When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Veteran is assigned a 30 percent evaluation for his service-connected PTSD from August 27, 2004, the date of claim, and a 50 percent evaluation from July 8, 2008, the date of a VA examination. As discussed below, the Board concludes that a 50 percent disability evaluation is warranted for the entire period from the date of claim, August 27, 2004; the previously established 50 percent evaluation from that later date should remain undisturbed. Thus, a staged rating is not appropriate for the Veteran's service-connected PTSD. The Veteran's service-connected PTSD is evaluated pursuant to 38 C.F.R. § 4.130, DC 9411. Under this formula, a 10 percent is granted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent evaluation is assigned 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is for assignment 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; difficulty establishing effective work and social relationships. A 70 percent evaluation is contemplated for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when there is evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. The use of the term 'such as' in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase 'such symptoms as,' followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. Apr. 8, 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 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 Global Assessment of Functioning (GAF) is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). As will be discussed below, the Veteran has been assigned GAF scores ranging from 49 to 60 as determined by VA examiners and treatment providers dating from 2004 to 2013. These scores are indicative of moderate to serious impairment. According to the DSM-IV, which VA has adopted pursuant to 38 C.F.R. §§ 4.125 and 4.130, a GAF score of 41 to 50 is reflective of 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). GAF 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). Initially, the record on appeal demonstrates that, in addition to the service-connected PTSD, the Veteran has been diagnosed with depressive disorder, not otherwise specified (NOS). See the VA examination report dated February 2013. Critically, the February 2013 VA examiner specifically determined that he was unable to clearly differentiate between the overlapping symptomatology. Specifically, the examiner stated that "[s]ymptoms of conditions overlap and exacerbate each other and are otherwise intertwined." The Board notes that when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2011); Mittleider v. West, 11 Vet App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so). Accordingly, the Board will consider the psychiatric symptoms, as depicted by the evidence as a whole in rating the service-connected PTSD. In this case, the Veteran seeks a disability rating in excess of the currently assigned 30 percent for his service-connected PTSD from August 27, 2004 and in excess of 50 percent from July 8, 2008. After having reviewed the record, and for reasons explained in greater detail below, the Board concludes that a 50 percent disability rating is warranted under the schedular criteria for the entire period dating from August 27, 2004; a rating in excess of 50 percent is not warranted. Here, Vet Center treatment records dated in July 2004 note the Veteran's complaints of poor sleep with nightmares and intrusive thoughts. The treatment provider also documented the Veteran's history of poor anger management and hypervigilance. It was noted that the Veteran's mood was depressed and affect was flat. The treatment provider indicated that the Veteran has "no close friends only relations and mostly is alone." A history of "decontrol anger" was also noted. The Veteran reported that he had not worked since 1983 and had a history of alcoholism, which had been in remission since 1987. Vet Center treatment records dated September 2004 through November 2004 characterized the Veteran as "cooperative, logical, and goal directed. Affect was somewhat dysphoric/constricted." The Veteran was initially afforded a VA examination in December 2004, at which time he described experiencing nightmares and flashbacks since returning from Vietnam. He denied suicidal or homicidal ideation, as well as, auditory or visual hallucinations. He indicated that he is distrustful of people. The Veteran stated that he had been divorced since the 1980's and has three adult children. He reported that he lives in "a variety of places" and "sometimes does odd jobs." The examiner reported that the Veteran was fairly groomed and maintained good eye contact. His speech was at a normal volume and rate. His mood was depressed and his affect was congruent to mood, not tearful. The Veteran denied any feelings of hopelessness, helplessness, or worthlessness. The examiner noted that the Veteran's memory was grossly intact and there was no difficulty with concentration. The Veteran endorsed hypervigilant, ritualistic behavior such as checking doors and windows. The examiner stated the Veteran did not exhibit paranoia, although he described himself as "distrustful of people." The examiner noted that the Veteran "is obsessed about his Vietnam war experience and the injury and ambushes he suffered." The examiner indicated that the Veteran "has the ability to maintain personal hygiene and other basic activities of daily living." He further reported "no inappropriate behavior observed . . . no suicidal or homicidal plans or intentions." The examiner additionally noted, "[t]here was no evidence of acute panic attacks on observation. Veteran has outbursts of anger, sleep impairment, impaired impulse control, and emotional instability." Exaggerated startle response was also indicated. The examiner concluded that the Veteran's PTSD "causes social functioning problems. Veteran has been socially isolated and avoids people. He has no friends." A GAF of 60 was assigned. In a February 2007 statement, the Veteran reported a history of violence and endorsed memory problems. He stated that his lives with his sister who helps him. He stated that he only leaves the house to come to the Vet Center and for medical appointments. He stated that he is "preoccupied [with] people and the harm they can do so I stay inside." He also stated that he hears a voice inside his head that starts telling him to "smash," so he stays inside. The Veteran was afforded a second VA examination in July 2008 at which time the VA examiner noted that the Veteran attends counseling once a week. He also sees a counselor at the Vet Center individually once every sixty days. The Veteran reported that he was divorced in 1983 and was subsequently in a relationship with a woman for fourteen years, who passed away in 1998. He has had no romantic relationships since then. With respect to his three adult daughters, he stated that he sees his oldest daughter often, as she lives nearby. He also sees his youngest daughter once a month, but speaks only occasionally via telephone with his middle daughter. He stated that he has not seen her in three years due to an argument with her boyfriend. He characterized his relationship with his children as "variable." The Veteran stated that he has one older sister with whom he speaks once a week and he has rented a room from his younger sister since 1999. He reported that they get along well. He has no contact with his older brother. Additionally, the Veteran stated that he has a female cousin with whom he visits three or four times a month. He reported that he has made friends at the Vet Center. He has gone to veteran conventions with a few of these Vet Center friends and occasionally gets coffee with them after group sessions. The Veteran also indicated that he recently joined the American Legion and has twice attended activities there. He further reported that he visits his deceased significant other's sister and her husband once a month to help them with grocery shopping. Aside from these social activities, the Veteran reported that he "mostly spends time in his room on the computer or watching television." He did not report any suicide attempts. He endorsed a history of violence/assaultiveness; specifically, he stated that he got into a physical altercation with the son of a woman he helps. The examiner noted that "[b]ased on his presentation and history over the last four years, here appears to be little change in his functioning since his PTSD examination." The July 2008 VA examiner noted that upon examination, the Veteran wore disheveled clothes. The examiner described the Veteran's mood as "elated, dysphoric;" although the Veteran stated that he has felt "depressed and angry" for many years with no changes. He indicated it does not interfere with his daily activities. The Veteran reported that "it doesn't take much to set me off." The examiner additionally noted that the Veteran's attention is intact, although he reported that his mind sometimes wanders when people talk to him and he feels impatient. He stated that with respect to disturbed sleep, he goes to bed around 12 A.M. and wakes up at 5A.M. He endorsed fair impulse control with no panic attacks, no episodes of violence, no problems with activities of daily living, and no problems maintaining minimum personal hygiene. The examiner noted that the Veteran "endorsed mild hypnogogic hallucinations in which he hears indiscernible voices. Only when he is 'half asleep.'" The Veteran's memory was described as normal. He endorsed hypervigilance and stated that he is "always on guard when out." The Veteran stated that, with respect to his anger, he walks into a room and thinks, "okay, who's gonna fight me." The examiner noted that the Veteran does "indicate ability to experience emotions, but doesn't like to express tender emotions." With respect to work, the July 2008 examiner noted that the Veteran last worked in 1983. According to the Veteran, he was fired for being late, drinking, and arguing with fellow employees. He subsequently performed odd jobs; however, after suffering from diverticulitis, the Veteran became seriously ill for several months and has not worked since. The VA examiner concluded that the Veteran "indicated moderate to severe levels of distress or dysfunction in many aspects of his life, including overall level of distress, social life, relationships with family, intimate relationships, work functioning, ability to enjoy leisure pursuits, and satisfaction with life." A GAF of 49 was assigned. VA treatment records dated September 2010 document the Veteran's report of problems with anxiety, irritability, awful memories, sleep, concentration, and too little energy. Notably, the treatment provider indicated that the Veteran "[r]eports engagement to fiancé and feeling much better." The Veteran endorsed a history of violence/dangerousness and stated, "I used to get into bar fights, get [fired] from jobs." An October 2010 VA behavioral health intake record noted the Veteran's report of difficulty getting to sleep and staying asleep. The Veteran's flashbacks, hypervigilance, and depression were also reported. It was further noted that the Veteran "hears voices at times, he says the voices tell him to hurt someone and to be on alert. He has no visual hallucinations or delusions." The treatment provider indicated that the Veteran experiences no current suicidal or homicidal ideation; however, he stated that the Veteran's "last suicidal thoughts [were] five years ago - he thought about driving off of a cliff." A GAF of 60 was assigned. VA treatment records dated December 2010 and February 2011 indicated that the Veteran went on a ten day cruise on which he "had a very good time." In September 2012, the Veteran and his significant other, Ms. S.Y., testified under oath at a Board hearing. The Veteran described PTSD symptoms including sleeplessness, hypervigilance, exaggerated startle response, and memory problems. See the September 2012 Board hearing transcript, pgs, 4, 10-11. Ms. S.Y. also reported that the Veteran gets "real depressed" and experiences anger "sort of." Id. at pg. 5. The Veteran endorsed suicidal ideation. Id. He further reported that he had no friends, but admitted that he considers the fellow veterans in group therapy to be 'friends.' Id. at pg. 6. The Veteran stated that his service-connected PTSD prevents him from working in that he has problems with authority. Id. at pg. 9. Ms. S.Y. testified that the Veteran is very suspicious and distrustful of people. Id. at pgs. 9-10. The Veteran stated that he easily becomes mad. Id. at pgs. 11-12. In a report of a VA psychiatry intake evaluation, it was noted that the Veteran was intermittently depressed with irritable mood, nightmares, flashbacks, vague paranoia, and occasional thoughts to hurt others. The Veteran reported that sometimes he will be out in public and see other people "talking and glancing at him and he wants to go over there and start a fight, but stops himself." He denied that he wants to hurt anyone specific. The Veteran also denied any recent suicidal ideation and hallucinations. The treatment provider noted that the Veteran was well-oriented with a normal thought process and did not seem psychotic. VA treatment records dated January 2013 indicated that the Veteran was participating in the Golden Age Games, a VA-sponsored event in upstate New York in May 2013 and was competing in the events of shot-put and swimming. VA treatment records dated April 2013 documented a GAF of 59. VA treatment records dated May 2013 noted the Veteran's stable mood and indicated that he is less irritable since restarting fluoxetine and "less apt to fly off the handle." VA treatment records dated July 2013 also reported the Veteran's mood to be generally stable and further noted that although the Veteran gets angry with his girlfriend on occasion, he has not been violent with her. He also denied any recent thoughts of self-harm. It was noted that the Veteran was "still mildly depressed, affect mildly constricted." A GAF of 63 was reported. Pursuant to the January 2013 Board Remand, the Veteran was afforded another VA examination in February 2013. The examiner indicated that the Veteran's psychological symptomatology was best described as "[o]ccupational and social impairment with reduced reliability and productivity." The examiner noted that the Veteran currently resides with his girlfriend. The Veteran reported that he remains involved in group therapy and individual counseling at the Vet Center and is seeking a medication consultation through the VAMC. He endorsed "a lot of problems with anger. I get set off really quickly. Get irritated and enraged at times." He also reported chronic sleep impairment including initial insomnia and nightmares that impact sleep. He reported occasional intrusive thoughts and "physiological/psychological distress upon exposure to reminders." He also reported a long history of avoidance of thoughts, feelings, and activities associated with his Vietnam experience. He endorsed feelings of detachment and a long history of social isolation. He also reported anger, hypervigilance, and hyper startle response. The examiner noted that although the Veteran reported a history of depressive symptoms, "he does report improvement in mood/depression since together with girlfriend. They have been together since October 2008." The Veteran reported "mild depressed mood, mild hopelessness, fair motivation, fair concentration, "pretty good" energy, and fair self-esteem. He denied anhedonia and current suicidal ideation. He denied auditory and visual hallucinations. The examiner noted that the Veteran exhibited a restricted range of affect and difficulty concentrating, in addition to the symptoms described above. The examiner also indicated that the Veteran had "disturbances of mood and motivation" as well as "difficulty in adapting to stressful circumstances, including work or a work like setting." A GAF of 50 was assigned. Based on a review of the evidence, the Board concludes that an increased initial rating of 50 percent, but no higher, is warranted for the Veteran's PTSD from August 27, 2004, the date of claim. Symptomatology warranting the assignment of a 50 percent rating includes impaired affect, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. Accordingly, resolving reasonable doubt in the Veteran's favor, the Board concludes that an increased rating to 50 percent, but no higher, is warranted based on the Veteran's manifested mood disorder symptomatology from August 27, 2004. See 38 C.F.R. § 4.3 (2012). The Board has considered the assignment of a rating in excess of 50 percent for the entire period. See A.B. v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the Rating Schedule, the pending appeal as to that issue is not abrogated). Critically, the VA and Vet Center treatment records as well as the December 2004, July 2008, and February 2013 VA examination reports did not show that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Rather, the findings of the VA examiners and treatment records are indicative of occupational and social impairment, with reduced reliability and productivity. The Veteran was shown to maintain social relationships with family members and exhibited an interest in activities outside of the home. The Board recognizes that the Veteran experiences irritability during the appeal period. See, e.g., the September 2012 Board hearing transcript & the VA examination reports dated December 2004, July 2008, and February 2013. Critically, there is no evidence that the irritability with outbursts of anger endorsed by the Veteran rise to the level of impaired impulse control such as unprovoked irritability with periods of violence as is contemplated for the assignment of a 70 percent rating. Crucially, the presence of certain symptoms is not necessarily determinative. These symptoms must also cause the occupational and social impairment in the referenced areas. See Vazquez-Claudio, supra. There is no indication that his occupational and social functioning was demonstrative of deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood from the date of claim. Moreover, total occupational and social impairment as a result of the Veteran's service-connected PTSD have not been demonstrated during the appeal period. The evidence has not shown total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting oneself or others; intermittent inability to perform activities of daily living; or disorientation to time or place. It is undisputed that the Veteran has a history of auditory hallucinations as described by the July 2008 VA examiner. Additionally, although the Veteran has claimed to have memory problems, there is no evidence of memory loss for names of close relatives, own occupation, or own name The Board recognizes that the Veteran has not been employed. However, the evidence of record does not show that his PTSD has caused total occupational impairment. Critically, although the Veteran has at times asserted that he is unable to work due to the irritability and problems with authority manifested by his service-connected PTSD, he previously reported that he stopped working as a result of his diverticulitis. See the VA examination report dated July 2008. No medical professional has provided any opinion indicating that the Veteran's PTSD has caused total occupational and social impairment. Accordingly, in this case, the symptoms shown in the VA and Vet Center treatment records as well as VA examinations do not equate to the symptoms contemplated for a 100 percent rating at any time during the appeal period. In sum, the extent and severity of the Veteran's actual PTSD symptoms reported and/or shown are suggestive of occupational and social impairment, with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood, impaired memory; depression; anxiety; irritability; and difficulty in establishing and maintaining effective work and social relationships; i.e., the level of impairment contemplated in the assignment of a 50 percent rating for psychiatric disabilities. See Mauerhan, supra, Vazquez-Claudio, supra. More severe symptomatology was not shown. Accordingly, and based on this evidentiary posture, the Board concludes that the totality of the evidence has shown that the Veteran's PTSD warrants a 50 percent rating, but no higher, from August 27, 2004, the date of claim. III. Additional Considerations The Board also finds that evidence does not show an exceptional or unusual disability picture as would render impractical the application of the regular schedular rating standards. See 38 C.F.R. § 3.321 (2012). The current evidence of record does not demonstrate that Veteran's PTSD has resulted in frequent periods of hospitalization or in marked interference with employment. Id. In this regard, the Board notes that it is undisputed that the psychiatric disorder has had some impact on the Veteran's occupational functioning, but it bears emphasis that the schedular rating criteria are designed to take such factors into account. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2012). Here, the Veteran's psychological symptoms are expressly contemplated by the criteria discussed above. 38 C.F.R. §§ 4.10, 4.40. Thus, given the lack of evidence showing unusual disability not contemplated by the rating schedule, the Board concludes that a remand to the RO for referral of this issue to the VA Central Office for consideration of an extraschedular evaluation is not warranted. ORDER An initial disability rating of 50 percent, but no higher, for the service-connected PTSD is granted from August 27, 2004, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to a disability rating for service-connected PTSD in excess of 50 percent disabling is denied. ____________________________________________ THOMAS H. O'SHAY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs