Citation Nr: 1327702 Decision Date: 08/29/13 Archive Date: 09/05/13 DOCKET NO. 08-32 327 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to higher initial evaluations for posttraumatic stress disorder (PTSD), rated as 10 percent disabling prior to January 12, 2009, and as 30 percent disabling from that date. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from August 1965 to February 1969. This matter comes before the Board of Veterans' Appeals (Board) from a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. That action granted service connection for PTSD and assigned a 10 percent evaluation; the Veteran disagreed with the evaluation assigned. The Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference in December 2009. A transcript of his hearing has been associated with the record. In February 2010 the Board remanded the appeal for additional development. While the case was in remand status, the agency of original jurisdiction (AOJ) granted a 30 percent evaluation, effective January 12, 2009. The Board notes that, on a claim for an original or an increased rating, the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulations, and it follows that such a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that the appellate record includes a Virtual VA e-file. Records contained in the e-file have been reviewed in the adjudication of the Veteran's appeal. FINDING OF FACT PTSD is productive of reduced reliability and productivity due to sleep disturbance, avoidance, feelings of detachment and estrangement, difficulty with relationships, increased arousal, irritability, depression, and passive suicidal and homicidal ideation. CONCLUSIONS OF LAW For the entire appellate period, the criteria for an initial evaluation of a 50 percent evaluation for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130; Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA 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. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. A letter dated in May 2007, prior to initial adjudication of the Veteran's claim for service connection, discussed the evidence necessary to support the claim. The evidence of record was discussed, and the Veteran was told how VA would assist him in obtaining additional relevant evidence. This letter also discussed the manner in which VA determines disability ratings and effective dates. The Board concludes that the content of the notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim. The Board further notes that this is a case in which the Veteran has challenged the initial evaluation assigned following the grant of service connection. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. With respect to VA's duty to assist, VA records have been obtained and associated with the record. The Veteran has been afforded VA examinations, and the Board finds that they were adequate in that they were performed by mental health clinicians who reviewed the file, conducted mental health status examinations and provided sufficient information for the Board to render an informed determination. The record also contains reports from the Veteran's VA treating providers. The Veteran has not otherwise identified any additional evidence or information which could be obtained to substantiate the claims. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Factual Background An August 2007 VA treatment record indicates that the Veteran was seen to establish primary care. He reported occasional sharp left sided pain, occurring at rest especially when he was aggravated or anxious, lasting for three to five seconds. He also indicated that he had increasing irritability in the mornings. The provider noted that the Veteran had been diagnosed with PTSD in December 2006. The Veteran endorsed flashbacks, and reliving traumatic events for minutes to hours at a time. He also endorsed upsetting dreams. He stated that he avoided thinking or talking about the traumatic event. He reported increased irritability and anger and reported difficulty with relationships outside his family. He indicated that he isolated himself. He related that he was easily startled and frightened, and that he felt paranoid, watching doors, scouting new surroundings, and sitting with his back to the wall. The diagnosis was PTSD. The Veteran was referred to the PTSD clinic. A VA phone contact note dated in August 2007 indicates the Veteran's report of trouble sleeping, depression, increased frustration and irritability, and flashbacks relating to military trauma. He denied suicidal and homicidal ideation, and alcohol and drug abuse. On screening consultation in August 2007, the Veteran's history was reviewed. He reported re-experiencing in the form of nightmares. He also reported that he jumped if his wife tried to wake him up, which the provider noted to be indicative of physiological reactivity. The Veteran endorsed flashbacks during which he briefly lost touch with reality. He reported that he avoided thoughts and feelings about Vietnam by drinking excessively from 1969 to 1974, and that he quit drinking following an accident in which he was burned. He related that he avoided crowds and tended to isolate himself in general. He also reported that he avoided movies about war and the news about current war. He noted that he had lost interest in things he used to enjoy, such as bowling, fishing, hunting, and dancing, and indicated that the only thing he retained interest was in his grandchildren. He endorsed a strong sense of estrangement or detachment from civilians, as he felt that they could not understand. Regarding hyper arousal, the Veteran reported that he got four hours of sleep. He noted that he was easily startled by loud unexpected noises. He also stated that he was easily irritated, and that he had a difficult time concentrating and staying focused. Mental status examination revealed a slightly anxious mood. The Veteran's thought processes were logical and coherent with no evidence of formal thought disorder. His affect was moderately restricted in range and level of intensity, but appropriate to content of thought. The Veteran denied hallucinations. He admitted to suicidal ideation but noted that it had been in the past and not recent. He also admitted to homicidal ideation but in thought only, with no plan. He was oriented with good insight and judgment. The diagnosis was PTSD. The provider assigned a global assessment of functioning (GAF) score of 50. A November 2007 follow-up note contains essentially the same report and findings. At that time, the same provider assigned a GAF score of 55. On VA examination in March 2008, the Veteran's history was reviewed. He reported that he had good relationships with his children, having moved from Texas to Tennessee following his retirement to be closer to them and to his grandchildren. He indicated that his relationship with his wife was strained. He stated that he would like to have social relationships and expressed a desire to have cookouts, but that his wife did not like to do that type of thing. He noted that he and his wife watched two of their grandchildren every week. He also indicated that he watched television "all of the time" and that he enjoyed reading novels. He reported that he used to enjoy fishing, hunting, car racing, and bowling, but had not participated in those activities since his retirement. He denied history of suicide attempts and history of violence. On examination, the Veteran was clean and casually dressed. He was unremarkable for psychomotor activity. His speech was spontaneous, and he was cooperative, relaxed, and attentive. His mood was good, and affect was appropriate. He was oriented. His thought process and content were unremarkable. Judgment and insight were intact and intelligence was average. The Veteran endorsed sleep impairment, and the provider noted that he had difficulty falling and staying asleep. He denied obsessive or ritualistic behavior, panic attacks, suicidal and homicidal ideation, and episodes of violence. Impulse control was good. The Veteran's memory was normal. With respect to PTSD symptoms, the examiner noted that the Veteran had persistent re-experiencing of traumatic events by recurrent distressing dreams, and intense psychological distress to cues symbolizing or resembling an aspect of the traumatic event. He noted that the Veteran made efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people arousing recollections of the trauma; and that he had feelings of detachment or estrangement from others. Symptoms of increased arousal were noted to include difficulty falling and staying asleep, and an exaggerated startle response. The examiner concluded that the disturbance caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. He noted that the Veteran had difficulty sleeping most nights and had nightmares about twice per week. He pointed out that the Veteran had a history of successful employment, good family relations, and an active social life including fishing, hunting, bowling, and car racing. He related his belief that the Veteran's symptoms were most likely sub-clinical during that time frame. He noted that the Veteran was not currently employed, but that he had retired when he was eligible by age or duration of work. He again noted that the Veteran had a history of successful and long-term employment. The examiner provided a diagnosis of PTSD and assigned a GAF score of 65. He concluded that there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning. An October 2008 VA outpatient record indicates the Veteran's report that he had stopped taking his anti-depression medication and that he was very moody and easily anxious. He endorsed thoughts of harming himself and others. The assessment was depression, anxiety, and PTSD. In January 2009, a VA provider noted that the Veteran had achieved a score on the Beck Depression Inventory-2 consistent with a severe level of depression. On interview, the Veteran acknowledged feeling depressed and having suicidal ideation as recently as the previous day, but denied current suicidal ideation or intent. The diagnosis was PTSD, and the provider assigned a GAF score of 45. In March 2009, the Veteran endorsed re-experiencing, hyper arousal, and avoidance. He indicated that most troublesome was a very low frustration tolerance, irritability, and depression. He also noted that he continued to wake up at night. He denied active suicidal and homicidal ideation, but endorsed some chronic passive thoughts. On mental status examination, the Veteran was oriented and well groomed. His speech was clear and productive. His mood was described as "better," and his affect was appropriate. His thought process was linear, logical, and goal directed with no evidence of looseness of association, overt psychosis, or delusions. Memory was grossly intact. Insight was fair. Judgment was intact. The assessment was PTSD with chronic significant symptoms including depression and irritability. The provider assigned a GAF score of 48. In August 2009 the Veteran reported continued difficulty sleeping despite reduction in alcohol and caffeine intake. He reported that a family trip to Texas for a family reunion went well. Objectively, he was oriented. His speech was clear and productive. His mood was irritable and his affect was restricted. He denied suicidal and homicidal ideation, as well as hallucinations. His thought process was linear, logical, and goal directed. There was no evidence of thought disorder. Memory was grossly intact. Insight was fair and judgment was intact. The diagnosis was PTSD with chronic significant symptoms including depression and irritability. The provider assigned a GAF score of 48. In December 2009 the Veteran reported continued difficulty sleeping and irritability. Objectively, he was oriented. His speech was clear and productive. His mood was irritable and his affect was restricted. He denied suicidal and homicidal ideation, as well as hallucinations. His thought process was linear, logical, and goal directed. There was no evidence of thought disorder. Memory was grossly intact. Insight was fair and judgment was intact. The diagnosis was PTSD with chronic significant symptoms including depression and irritability. The provider indicated that irritability had decreased with medication but that it still interfered with relationships. He assigned a GAF score of 48. At his December 2009 hearing, the Veteran testified that he was treated by VA for his PTSD, and that he received medication for sleep, anxiety, and depression. He indicated that he did not attend group therapy because he did not like group settings. With respect to his symptoms, he related that he suffered from depression and hopelessness. He endorsed suicidal thoughts. He described anxiety, especially when driving. He indicated that he had panic attacks, and described an incident while shopping in a crowded store with his wife, noting that he had to walk out. He described two occasions when he was reprimanded at work. He indicated that he retired based on time from the Texas Department of Corrections. He also indicated that he completed his military career with the Army National Guard, following more than 22 years. He noted that he achieved the rank of Sergeant First Class and would have stayed longer if he had made First Sergeant. He expressed a desire to go out dancing and to attend car races, but indicated that he could not handle the crowds. With respect to the aforementioned Board hearing, the Court of Appeals for Veterans Claims held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the 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, the VLJ noted the current appellate issue at the beginning of the hearing, and asked questions to clarify the Veteran's contentions concerning functional impairment and treatment history. Following the hearing, the case was remanded in order to obtain additional VA treatment records and to afford the Veteran a VA examination. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. An April 2010 VA record indicates that the Veteran was alert, oriented, and able to perform math and memory exercises following distractions. Grooming and hygiene were good. The Veteran's mood was depressed. Alternatives to suicidal behavior were discussed. The provider opined that the Veteran was at least as disabled as the current 10 percent award for PTSD. He assigned a GAF score of 42. In June 2010, a VA physician noted that the Veteran was doing better with medication and would continue to be followed in the clinic. On VA examination in June 2010, the Veteran's history was reviewed. The Veteran related that he saw his children often and that he got along with his family. He indicated that he did woodworking. He noted that he quit fishing and hunting after he moved to Tennessee. He denied a history of suicide attempts and of violence. He reported that he avoided crowds and tended to isolate himself. He stated that he would like to go the races at Bristol but that he did not think he could tolerate the crowds. He stated that his only current interests were woodworking, his children, and his grandchildren. On examination, the Veteran was casually dressed. With regard to psychomotor activity, the examiner noted that the Veteran was restless and appeared fatigued. The Veteran's speech was spontaneous, clear, and coherent. In describing his mood, the Veteran stated that "I just don't care." His affect was constricted. Attention and orientation were intact. The examiner noted that the Veteran's thought process involved rambling and circumstantiality. Suicidal ideation was noted. Judgment was intact. Regarding insight, the examiner noted that the Veteran partially understood that he had a problem. There was no inappropriate behavior. The Veteran had mixed results in interpreting proverbs, giving three out of five appropriate answers. He reported that his sleep was better since starting a CPAP machine a month previously. There was no obsessive or ritualistic behavior, and the Veteran denied panic attacks and homicidal ideation. He endorsed suicidal ideation, but assured the examiner that he had no intention of hurting himself. He reported that he had been better able to control his acting out. His remote and immediate memory was normal; recent memory was mildly impaired. With respect to PTSD symptoms, the examiner noted that the Veteran persistently re-experienced traumatic events by feeling as if the traumatic event was recurring, and intense psychological distress at exposure to cues symbolizing or resembling an aspect of the trauma. He noted that the Veteran avoided thoughts, feelings, or conversations associated with the trauma and avoided activities, places, or people arousing recollections. He also indicated that the Veteran had feelings of detachment or estrangement from others. Regarding increased arousal, he noted that the Veteran experienced irritability or outbursts of anger, hyper vigilance, and exaggerated startle response. He concluded that the disturbance caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The diagnosis was PTSD. The examiner assigned a GAF score of 49. He noted the Veteran's report that he never allowed his PTSD symptoms to adversely impact his work performance. He also noted the Veteran's description of on-and-off moments of suicidal ideation that he attributed to his wife's behavior. He concluded that there were signs and symptoms that were transient or mild and decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. He explained that the Veteran described periods of significant marital distress in which he had suicidal ideation; however, he stated that PTSD never adversely impacted his work and that he got along with coworkers but did not want to have anything to do with anyone but family after work. An October 2010 psychology team note indicates the Veteran's report of no changes in his problems, goals, or interventions. The diagnosis was PTSD and the provider assigned a GAF score of 44. During a June 2011 medication check, the Veteran was alert, coherent, and communicative. He was not suicidal. He was appropriately attired with good grooming and hygiene. The assessment was PSTD and the provider assigned a GAF score of 44. Analysis Disability evaluations are determined by the application of a schedule of ratings, which is based on average industrial impairment. 38 U.S.C.A. § 1155. A proper rating of the Veteran's disability contemplates its history, 38 C.F.R. § 4.1, and must be considered from the point of view of a Veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board observes that in cases where the original rating assigned is appealed, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered whether staged ratings are warranted. It has determined that the Veteran's PTSD has not significantly changed, and that a uniform rating is for application. Under the rating criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012), a 100 percent evaluation is provided for PTSD where 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; memory loss for names of close relatives, own occupation, or own name. A 70 percent evaluation is provided where there is 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 or hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 50 percent evaluation is appropriate where there is reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent disability rating is appropriate where the evidence shows that PTSD is productive of 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 normal conversation), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (i.e., forgetting names, directions, and recent events), warrants a 30 percent disability evaluation. A 10 percent evaluation is warranted where there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. In evaluating psychiatric disorders, it must be shown that industrial impairment is the result of actual manifestations of the service-connected psychiatric disorder. The severity of a psychiatric disability is based upon actual symptomatology, as it affects social and industrial adaptability. Two of the most important determinants of disability are time lost from gainful employment and decrease in work efficiency. 38 C.F.R. § 4.130 (2012). In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet.App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating 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 score of 61-70 is assigned where there are mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, of theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Upon careful consideration of the evidence pertaining to this claim the Board has determined that for the entire appellate period, an evaluation of 50 percent is warranted for the Veteran's PTSD. The Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under-or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, 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. This construction is not inconsistent with Cohen v. Brown, 10 Vet.App. 128 (1997). The Board acknowledges that evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. 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 (1992). In this case, the Board observes that the Veteran's reported symptoms include sleep disturbance marked by recurring nightmares; chronic depression; irritability; chronic hyper arousal; avoidance of cues that symbolize or resemble an aspect of the traumatic event; avoidance of activities, people, and places that arouse recollection of trauma; passive suicidal and homicidal ideation; restricted affect; and irritability and outbursts of anger. Moreover, the Board accepts that the Veteran's PTSD impacts his relationship with his wife. There is evidence of restricted affect, mood disturbance, some difficulty concentrating and focusing, as well as mildly impaired recent memory. The evidence also shows a difficulty with respect to establishing and maintaining effective social relationships outside of his family and one examiner noted a circumstantial thought process. In essence, the evidence reflects symptoms that are best contemplated by the criteria for a 50 percent evaluation. The Board has also determined that an evaluation in excess of 50 percent is not warranted. The Board acknowledges that the Veteran's PTSD is manifested by disturbances in affect and mood, passive suicidal and homicidal ideation, and sleep problems, which were already considered in assigning the 50 percent evaluation. However, the evidence does not demonstrate deficiencies in most areas. Rather, as noted, the Veteran had a successful career and engaged in various social and recreational activities prior to his retirement. There has been no demonstration of symptoms such as obsessive rituals interfering with routine activities; intractable panic or depression to the extent that if affects the ability to function independently, appropriately and effectively; speech disturbance; or spatial disorientation. Judgment and insight are intact, although insight has been noted to be only fair by some providers. The Veteran's hygiene has been noted to be good. There is no indication that any of the Veteran's psychiatric symptoms affect his ability to function independently, appropriately, and effectively. No impairment of impulse control has been recorded, although the Veteran does endorse difficulty with anger. While there has reportedly been an impact on the Veteran's interpersonal functioning with regard to his wife, the record does not reflect the difficulty contemplated by the diagnostic criteria for a higher rating. In that regard, the Veteran reports good relationships with his children and grandchildren. In sum, while the Board accepts that the Veteran's PTSD has effects on his functioning, the lay and medical evidence of record does not demonstrate the impairment in judgment, abstract thinking, motivation and mood, or the difficulty in establishing and maintaining effective work and social relationships contemplated by the criteria for a higher evaluation. Rather, the Veteran has repeatedly been found to be oriented with intact thought processes, and while he has, at times, endorsed suicidal ideation and thoughts of harming others, he has denied any plan with respect to those thoughts. Moreover, those symptoms were already considered in determining that a 50 percent evaluation was warranted. As such, the Board finds that the record as a whole does not support the existence of symptoms such that the criteria for a 70 percent evaluation are approximated. The Board acknowledges that VA records include some GAF scores ranging from 42 to 50. For example, outpatient treatment records reflect a GAF score of 42 in April 2010, but at that time, the Veteran denied suicidal and homicidal ideation and hallucinations, and his thought processes, memory, insight and judgment were intact. The records also show recent GAF scores of 44 in October 2010 and January 2011; however, the October 2010 note indicates no changes in the Veteran's reported problems, and the June 2011 record indicates that he Veteran was alert, coherent, communicative, and was not suicidal. Moreover, although the June 2010 VA examiner assigned a GAF score of 49, he went on to state that the Veteran had never allowed his PTSD symptoms to adversely impact his work performance, and that his symptoms were transient or mild. The Board additionally notes that a GAF score does not automatically equate to any particular percentage in the Rating Schedule. Rather, it is but one factor to be considered in conjunction with all the other evidence of record. 38 C.F.R. §§ 4.2, 4.6. As discussed above, after considering the symptoms manifested, and the duration and severity thereof, the Board finds that the criteria for a 50 percent rating, but no higher, are met. While the Veteran's depression has been assessed as severe and the Veteran experiences suicidal thoughts, the overall level of psychiatric impairment more nearly approximates occupational and social impairment with reduced reliability and productivity as a result of the depression and other symptoms manifested. Since the Veteran has been diagnosed as having psychiatric conditions in addition to the service-connected PTSD and the symptoms attributable to other psychiatric conditions have not been disassociated from his service-connected disorder, the Board has considered all psychiatric symptoms in reaching the above conclusion. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In summary, the overall disability picture does not more nearly approximate the criteria for a schedular evaluation of 50 percent. As such, the Board concludes that a 50 percent evaluation for the Veteran's PTSD for the entire period on appeal is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). Extraschedular Consideration The Board has also considered whether the Veteran's PTSD presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. In particular, the Veteran's symptoms as described in detail above are specifically contemplated by the rating criteria. Consequently, the Board has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Finally, where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). TDIU may be a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran retired for nonservice-connected reasons and has not alleged that he is unemployable due to his psychiatric disorder. Moreover, there is no evidence of unemployability, accordingly, TDIU is not raised by the record. ORDER Entitlement to an initial evaluation of 50 percent for PTSD is granted, subject to the laws and regulations controlling the award of monetary benefits. ___________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs