Citation Nr: 1327389 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 10-22 053 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to a higher initial disability evaluation (rating) for posttraumatic stress disorder (PTSD), in excess of 30 percent from June 12, 2008 to May 21, 2012, and in excess of 50 percent from May 21, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is also the appellant, had active service from May 1968 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Cleveland, Ohio, which granted service connection for PTSD and assigned a 30 percent initial disability evaluation from June 12, 2008. The Veteran filed a notice of disagreement with the assigned disability evaluation and perfected the appeal. In a June 2012 rating determination, the RO assigned a higher 50 percent disability evaluation for PTSD for the period from May 21, 2012. The RO's actions have created a "staged" initial rating of 30 percent for the period from June 12, 2008 to May 21, 2012 and 50 percent from May 21, 2012, which is reflected on the title page of this decision. FINDINGS OF FACT 1. For the entire rating period, PTSD has been characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as intermittent periods of anger and fluctuations of mood, anxiety and depression, mild memory impairment, disturbances of mood and motivation, sleep impairment, and the ability maintain close relationships only with immediate family members. 2. For the entire rating period, PTSD has not been characterized 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 obsessional rituals which interfered 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for a 50 percent disability evaluation for PTSD have been met or more nearly approximated from June 12, 2008. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a disability evaluation in excess of 50 percent for PTSD at any time during the appeal period have not been met or more nearly approximated. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the agency of original jurisdiction (AOJ) issued a notice letter to the Veteran in August 2008. The August 2008 letter explained the evidence necessary to substantiate the claim for service connection, as well as the legal criteria for entitlement to such benefits. The letter also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As the Veteran's appeal arises from his disagreement with the initial rating following the grant of service connection, no additional notice is required. The Court and the Circuit Court have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date). As it relates to the duty to assist, the Board finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, VA treatment records, VA examination reports, and lay evidence. No additional pertinent evidence has been identified by the claimant. The Veteran was afforded VA examinations in March 2009 and May 2012. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the examination reports set forth a history, assessments of social and industrial impairment, and detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examinations to be adequate for rating purposes. The examination reports provided a history supplied by the Veteran and detailed examination results. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and by being afforded the opportunity to appear at a hearing if so desired. As to the right for a hearing, the Board notes that the Veteran, in his May 2010 substantive appeal, requested that he be afforded a Travel Board hearing at the RO. In September 2011, the Veteran withdrew his request for a hearing. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). In this case, the Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Initial Rating for PTSD 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. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. See 38 C.F.R. § 4.3. Where 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). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The General Formula for Rating Mental Disorders, Diagnostic Code 9411, provides that a 30 percent rating is assigned for 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 requires 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 abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned 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 worklike setting); inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent evaluation is assigned 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 inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The symptoms cited above follow the phrase "such symptoms as" which indicates 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 the symptoms, or their effects, that would justify a particular rating. Accordingly, the Board has not required the presence of all or most of the enumerated symptoms for any particular rating. The list of symptoms merely provides guidance as to the severity of 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 the claimant's social and work situation. The Board must consider all symptoms of the veteran's condition which affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 441-443 (2002). The Global Assessment of Function (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM), 32 (4th ed.) (1994) (DSM IV); 38 C.F.R. §§ 4.125, 4.130 (2012). GAF scores from 71 through 80 is indicative that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more that slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). Scores ranging from 61 through 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 through 60 reflect 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 through 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). A GAF score of from 31 through 40 contemplates some impairment in reality testing or communication (e.g., speech 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). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Veteran contends that the symptomatology and impairment associated with his PTSD demonstrates that an evaluation in excess of 30 percent prior to May 2012 and in excess of 50 percent from May 2012 is warranted as a result of his PTSD causing flashbacks, nightmares, difficulty sleeping, avoidance of large crowds, startle reactions, preoccupation with checking locks and the perimeter, anxiety, depression, and difficulty establishing relationships with others other than close family. Treatment records obtained in conjunction with the Veteran's claim reveal that at the time of January 2008 visit, the Veteran was found to be oriented times three and to have a cooperative attitude. His mood was stable and his affect was appropriate and animated. His thinking was organized and goal directed and speech was found to be within normal limits. Insight and judgment were good and the Veteran had no homicidal or suicidal thoughts. Similar findings were made at the time of February and March 2008 visits, however, the Veteran's mood was noted to be depressed. In April 2008, the Veteran was noted to be neat and casually dressed. His speech had a normal rate, rhythm, and tone. His mood was angry and his affect was irritable. His thoughts were organized and there were no overt delusions. The Veteran had mild paranoia but denied flights of ideas, perceptual disturbances, ideas of reference, or thought broadcasting. He was alert and oriented times three and his concentration was reported as good, with intact memory, and fair insight and judgment. He denied suicidal or homicidal ideation. In May 2008, the Veteran was seen at the psychiatric emergency room with complaints of suicidal/homicidal ideations. His wife stated that he had been taking his psychiatric medications and drinking shots and beers. Mental status examination performed at that time revealed he was calm and cooperative and had good eye contact. He was intoxicated and his mood was euthymic. Speech had a normal tone, rate, and volume. There were no suicidal or homicidal ideations. Cognition was intact and thought process was linear and logical. The Veteran had no hallucinations or delusions. Insight and judgment were noted to be partial. The examiner rendered Axis I diagnoses of PTSD and alcohol abuse vs. dependence. A GAF score of 45 was assigned. At the time of an October 2008 pain management psychology visit, the Veteran was noted to be having headaches and neck pain. The Veteran was focused on the pain and it was difficult to get him to answer questions. He stated that he had retired two years earlier because of head and neck pain. The Veteran's marriage appeared to be suffering although his wife was present at the interview. The Veteran reported that he was spending less time with his grandchildren as they were very active. The Veteran indicated that a typical day was lying on the couch and watching television. Mental status examination revealed he was neatly dressed and alert and cooperative. He made eye contact and was oriented times three. The Veteran commented that he saw and heard things but these appeared to be trauma related as opposed to a psychotic process. His affect was constricted and his thought process was goal directed with no derailment, loose associations, or thought blocking. There were no delusional or paranoid signs. The Veteran denied having any suicidal/homicidal intentions. At the time of November and December 2008 and January and February 2009 visits, the Veteran was noted to be well groomed and to have a pleasant demeanor. His speech was within normal limits and his mood was stable. He was oriented times three. Thought process was noted to be logical and goal directed. The Veteran denied suicidal or homicidal ideations and insight and judgment were good. At the time of a March 2009 visit, the Veteran was noted to pose no imminent risk to himself or others. The Veteran reported that his mother had died last week. He stated that it was both a relief and sad. The Veteran indicated that he continued to have night sweats, intrusive thoughts, emotional detachment, and irritability/anger. He also reported having hypervigilance and disturbed sleep, getting up and sitting on the edge of the bed, and checking the house in the middle of the night. Mental status examination revealed he was casually dressed and groomed. The Veteran had been married since 1970 and had a good relationship with his children and grandchildren. He was active with the VFW and loved fishing and volunteering. The examiner rendered Axis I diagnoses of depression, PTSD, alcohol and cannabis abuse. A GAF score of 58 was assigned. At the time of a March 2009 VA examination, the Veteran reported that he was married and had two children. The Veteran acknowledged suicidal thoughts in the 1970's but had no plans. He reported that since retirement he had been involved with the VFW and worked in a volunteer position. The Veteran acknowledged violent behavior but denied aggressive behavior. He stated that he became involved in a verbal altercation when someone cut him off while driving. He indicated that he did not mind telling people what he thought and would become physical. Mental status examination revealed his behavior was cooperative. He was alert and oriented times three. Speech was normal in rate, rhythm, pace, tone, and volume. He denied suicidal/homicidal ideation or any auditory hallucinations. He acknowledged some visual hallucinations, images of Vietnamese squatting down with rifles. He would wake up and check the house. The images appeared in his peripheral vision. Judgment and insight were noted to be fair. The Veteran stated that he often checked and rechecked the locks and checked the woods for intruders. He also appeared to be quite hypervigilant. Testing revealed a person with unusual somatic complaints and peculiar ideas about health care. The Veteran reported that he was having cognitive difficulty, distractible, confused, having memory problems, and finding it hard to concentrate. The examiner also noted that testing revealed avoidant behavior and intrusive thoughts sometimes. The examiner stated that the Veteran complained of nightmares, sweats, irritability, anger, disrupted sleep, and hypervigilance. He also noted that the Veteran reported having difficulty with sleeping, elimination habits, and highway driving. The examiner further indicated that the Veteran reported experiencing visual hallucinations, seeing images of Vietnamese in his peripheral vision. Axis I diagnoses of PTSD and alcohol abuse were rendered, with a GAF score of 58 being assigned. VA outpatient treatment records covering the time period from March 2009 through January 2010 reveal that the Veteran was oriented times three and appropriately dressed with no notations of suicidal or homicidal thoughts and at least fair judgment and insight with varying moods and reports of mild anxiety, along with normal thought content. There were no notations of delusions or paranoia. Concentration was also reported as at least fair during this time period. In February 2010, a GAF score of 52 was assigned. At the time of a March 2010 visit, the Veteran was again noted to be well groomed and to have a pleasant and cooperative demeanor. Speech was within normal limits and the Veteran's affect was described as normal with a stable mood. He was oriented times three and his thought process was logical and coherent. There were no suicidal or homicidal ideations and insight and judgment were described as good. Similar findings were reported in April 2010 with the exception of the Veteran's affect being tearful and crying and his insight being described as poor and judgment fair. In a May 2010 letter, the Veteran's VA fee basis clinical psychologist indicated that the Veteran had once knocked his boss unconscious. She also noted that the Veteran was easily provoked to physical altercations at the VFW. She stated that he had had two altercations at the VFW in the past year. She noted that the Veteran's problems had forced him to work the night shift at Ford when he was previously employed. She stated that it seemed beyond debate that intentionally knocking your boss unconscious interfered with effective relationships. She also indicated that it seemed that having physical altercations with the customers of VFW, where the Veteran volunteered, showed some questionable judgment. She stated that it seemed to be an example of "impaired impulse control" which was compensated at the 70 percent level. At the time of a July 2010 visit, mental status examination revealed the Veteran was appropriately dressed. His demeanor was talkative and engaged, speech was within normal limits, affect was normal, mood was stable, thought process was logical and goal directed, and there were no suicidal or homicidal ideations. Insight and judgment were noted to be fair. Similar findings were made at the time of August 2010, July 2011, August 2011, September 2011, and October 2011, and April 2012 visits. The Veteran was noted to have been in group therapy throughout this time period. At the time of a May 2012 VA examination, the Veteran was diagnosed as having Axis I diagnoses of PTSD and major depression. A GAF score of 55 was assigned. The examiner indicated that the Veteran's level of occupational and social impairment was best described as 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 Veteran denied any significant changes in family functioning and noted that his mother had died two years ago. He indicated that he saw his children about once a month as they were busy with their children but he regularly spoke with them on the phone. He also spoke to his siblings periodically. He noted that his relationship with his wife had not improved despite being in therapy. He stated that rather than arguing with her he would just leave. He continued to be active at the VFW and had been elected to be the commander. He went there at least weekly. He stated that he had a couple of friends from his PTSD group that he went fishing with a few times a year. He mostly liked to be alone. In good weather he would going fishing every day, hours at a time. He did not like talking to people more than 5 minutes as he was unable to concentrate. He also indicated that he did not like to talk to any of his neighbors. The Veteran reported being in psychotherapy groups every other week. It was noted that he had been assigned GAF scores of 52 and 55 at the time of November and December 2011 visits. The Veteran stated that the VFW where he volunteered had been sued for sexual harassment, which he felt was unfounded. He noted that he had been involved in one altercation at VFW when he tried to intervene with someone who was acting inappropriately and the person grabbed him. There had been no other incidents of violence. The examiner indicated that the Veteran's PTSD caused symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, panic attacks that occurred weekly or less often, mild memory loss, flattened affect, impaired judgment, impaired abstract thinking, and disturbances of motivation and mood. The examiner stated that the Veteran continued to meet the criteria for PTSD and that he had moderate-severe re-experiencing symptoms. The examiner noted that the Veteran reported going into a "stupor" for a few hours two to three times per week, usually at night, when he sat up and thought about Vietnam. He reported having flashbacks six to seven times per year and waking up sweating from nightmares twice a month. He further reported having difficulty falling and staying asleep. The Veteran noted keeping himself busy so he would not have to think about Vietnam and stated that he had difficulty having conversations longer than 5 minutes as he would think of Vietnam and not be able to concentrate. The Veteran noted being less angry than he used to be and believed that cutting back on drinking may have helped. The Veteran stated that he felt detached from those who were not in Vietnam or part of his immediate family. He also reported that he was hypervigilant and startled easily. It was noted that the Veteran scored in the severe range on testing for depression and anxiety. After a review of all the evidence, lay and medical, and resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for a 50 percent disability evaluation for PTSD have been met throughout the course of the appeal, which results in a grant of higher initial disability rating of 50 percent for the initial rating period from June 12, 2008 to May 21, 2012. The Veteran has been shown to have intermittent periods of anger and fluctuations of mood, as well as anxiety and depression throughout he appeal period. He has also been found to have mild memory impairment during this time. Disturbances of motivation and mood have also been found to be present during the time period in question. Although the Veteran has a good relationship with his children and grandchildren, he has reported having difficulties with his marriage, despite remaining married. The Veteran has also indicated that he prefers isolation and that he does not like to talk to others for more than five minutes. In addition, the GAF scores assigned, with the exception of the GAF score assigned at the time of the May 2008 emergency visit, reflect 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). Therefore, resolving reasonable doubt in the Veteran's favor, the criteria for a 50 percent evaluation for PTSD have been more nearly approximated since the initial grant of service connection for PTSD, resulting in a grant of disability rating of 50 percent for the initial rating period from June 12, 2008 to May 21, 2012.. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. After a review of all the evidence, lay and medical, the Board finds that the criteria for a disability evaluation in excess of 50 percent have not been met or nearly approximated at any time during the initial rating appeal period. The Board finds that the Veteran's PTSD symptoms were not shown to be more than moderate in degree and only moderately impacted social and occupational functioning. The Veteran's PTSD symptoms and the severity of his symptoms did not more nearly approximate the criteria for a 70 percent disability (occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood) at any time. 38 C.F.R. §§ 4.3, 4.7. The Veteran has not been shown to have suicidal plans or intentions. There were no findings or assertions of suicidal or homicidal plans or intentions at the time of either VA examination or in the numerous VA outpatient treatment records which have been associated with claims folder with the exception of the Veteran reporting that he had thought about suicide at the time of his May 2008 emergency room visit. While the Veteran was noted to check the locks and windows at night prior to going to bed, there were no obsessional rituals found which interfered with routine activities. Speech has not been found to be intermittently illogical, obscure, or irrelevant at any time during this period, including at the time of both VA examinations. While depression has been diagnosed intermittently throughout the appeal, it has not been found to be near-continuous. Although the Veteran has reported being irritable and easily provoked and several instances of physical altercations have been reported, the Veteran still remains in his volunteer capacity and was recently reelected commander of the VFW, the place of several of his prior altercations. He has been found to be alert and oriented to time, place, and person all times and there have been no findings of neglect of personal appearance or hygiene. As to relationships, while the Veteran has reported that he tends to isolate and prefers to be alone, he still remains married and has reported having good relationships with his children and grandchildren. Furthermore, the numerous GAF scores in the 50's, including at the time of both VA examinations, are indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, 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 between rating evaluations would be extremely ambiguous. Id. at 442. With this in mind, the evidence shows that the Veteran's overall PTSD picture prior is adequately contemplated by the existing 50 percent rating. The Veteran does suffer from sleep problems, but this is specifically listed under the criteria for a 30 percent rating, a lower rating than the current 50 percent evaluation. Flattened affect, disturbance of motivation and mood, and difficulty in establishing and maintaining relationships are specifically contemplated in the 50 percent rating criteria. The same is true with the Veteran's depression and anxiety, which are both symptoms contemplated under the 30 percent PTSD disability rating. A 50 percent PTSD disability rating also considers "disturbances of motivation and mood" which would include the Veteran's reported depression and anxiety symptoms. Despite the Veteran's contention that his PTSD symptoms warrant an evaluation in excess of 50 percent, the Board finds that the evidence of record does not support this contention. For these reasons, the Board finds that a preponderance of the evidence is against a rating in excess of 50 percent for PTSD at any time. As the preponderance of the evidence is against a higher rating for any period, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the schedular rating criteria contemplate the impairments and symptoms associated with the Veteran's PTSD. The symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested flashbacks, nightmares, difficulty sleeping, avoidance of large crowds, difficulty associating with others other than his immediately family, intermittent obsessional rituals, and irritability. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. In the absence of exceptional factors associated with this disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER A 50 percent evaluation for PTSD from June 12, 2008 to May 21, 2012, is granted; a higher disability evaluation than 50 percent during the appeal period is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs