Citation Nr: 1328769 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 09-20 379 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUE Entitlement to increases in the ratings for post-traumatic stress disorder (PTSD), currently assigned "staged" ratings of 50 percent prior to December 5, 2012, and 70 percent from that date. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from April 1964 to April 1966. This matter is before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Roanoke, Virginia RO. In August 2012, a Travel Board hearing was held before the undersigned; a transcript of the hearing is included in the claims file. This matter was previously before the Board in October 2012, at which time it was remanded for additional development. An interim (February 2013) rating decision increased the rating for PTSD to 70 percent effective December 5, 2012. The issue is characterized to reflect that "staged" ratings have been assigned, and that both "stages" remain on appeal. FINDINGS OF FACT 1. Prior to December 5, 2012, the Veteran's PTSD was not shown to have been manifested by symptoms productive of impairment greater than occupational and social impairment with reduced reliability and productivity; PTSD symptoms productive of occupational and social impairment with deficiencies in most areas were not shown. 2. From December 5, 2012, the Veteran's PTSD is not shown to have been manifested by symptoms productive of impairment greater than occupational and social impairment with deficiencies in most areas; PTSD symptoms productive of total occupational and social impairment are not shown. CONCLUSION OF LAW Ratings for the Veteran's PTSD in excess of 50 percent prior to December 5, 2012 and/or in excess of 70 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.130, Diagnostic Code (Code) 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of his claim. March 2008 and December 2008 letters explained the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing, and informed him of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record, and has not alleged that notice was less than adequate. At the August 2012 Travel Board hearing before the undersigned, the Veteran was advised of what he still needs to substantiate the claim; his testimony reflects that he is aware of what is still needed to substantiate his claim. The Veteran's pertinent post-service treatment records have been secured. The RO arranged for VA examinations in March 2008, November 2011, and December 2012 (with an April 2013 addendum), which will be discussed in greater detail below, though the Board finds these examinations (cumulatively) to be adequate as they included both a review of the Veteran's history and a mental status examination that included all necessary findings. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Veteran has not identified any evidence that remains outstanding. VA's duty to assist is also met. Legal Criteria, Factual Background, and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. PTSD is rated under the General Rating Formula for Mental Disorders. A 50 percent rating is warranted 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 in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when 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 and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9411. The Veteran has been assigned various Global Assessment of Functioning (GAF) scores for his PTSD. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Lesser scores reflect increasingly severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes]. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remissions. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, and in Virtual VA, with an emphasis on the evidence that is relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence. See Gonzales v. West, 218 F, 3d, 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran's claim for an increased rating for PTSD was received in January 2008. The relevant appeal period is therefore from January 2007. On March 2007 VA treatment, the Veteran reported that his sleep had clearly improved on Imipramine and, overall, his anxiety symptoms were better on a combination of Imipramine and Xanax. No evidence was seen of progressive dysphoria or any sense of hopelessness, helplessness, worthlessness, or exaggerated guilt. His appetite was unchanged from previous visits and his daytime energy level, while chronically low, had not changed. He continued to report nightmares, yet there were no recent psychotic symptoms, prominent cognitive deficits, or substance abuse. On mental status examination, the Veteran was clean and well groomed, and showed normal psychomotor activity, good eye contact, and normal impulse control. His speech was within normal limits. His affect was a bit more dysphoric with restricted range initially but brightened considerably as the interview progressed, and he was laughing and joking by the end of the interview. His judgment was intact and his insight was fair. His thoughts were circumstantial at times but there was no looseness of associations or flight of ideas noted. No delusional thought was evident. His perceptions were without hallucinations or illusions. The assessments included PTSD, resolved grief reaction, recurrent major depression in remission, history of alcohol abuse in sustained remission, tobacco dependence, and history of adjustment disorder with mixed emotional features, with an Axis II assessment of cluster B personality traits. On September 2007 VA treatment, the Veteran reported that an increase in arthritis-related pain had led to some increase in his irritability and nightmares. His mood was essentially euthymic with only minimal irritability noted. There was no evidence of persistent or progressive dysphoria, hopelessness, helplessness, worthlessness, or exaggerated guilt; he looked forward to the birth of a new grandson early the following year. There were no psychotic symptoms, and there was no prominent suicidal or homicidal ideation, intent or plan. There were no recent substance abuse or any prominent cognitive deficits. The assessments were the same as on March 2007 treatment. In a December 2007 medical summary letter, the Veteran's treating psychiatrist noted that he had been treating the Veteran since 1998, providing both psychiatric care and medical care. Dr. Moles stated that the Veteran's disabilities include PTSD, recurrent major depression (now in remission), adjustment disorder now in remission, and a history of tobacco dependence in partial remission. He had a distant history of alcohol abuse which had been in sustained remission. He also had a number of medical problems. Dr. Moles stated that the Veteran was on a variety of medications, including Imipramine and Xanax for PTSD and recurrent major depression. The Veteran was noted generally to have been fully compliant with follow-up and treatment. On March 2008 VA examination, the Veteran was noted to be on Imipramine and Xanax, which were helpful although there was still PTSD symptomatology noted. The Veteran reported that he had been out of work since 1979, when he last worked driving a truck; he stated that being on various medications and his health problems had gotten in the way of his working. He reported that his brother, sister, and father lived in the area and he would occasionally see them and get along adequately with them; he got along adequately with his two sons as well, and he would occasionally see the one who lived nearer to him. He reported that he had a couple of friends whom he saw perhaps once per month to get together and talk. He reported that, every three months or so, three to four others would gather at his place to play cards with him; otherwise, he usually tried to avoid most people, especially in crowds. He disliked groups. On the occasions he went to a restaurant, he would sit with his back to the wall. He usually spent his time watching television, taking naps, reading, or performing various household tasks. He no longer went hunting but would fish two to three times per year. He denied any substance abuse problems, violent or assaultive behavior, or suicide attempts. On mental status examination, the Veteran's affect was very restricted and his mood was dysphoric with some underlying anxiety and underlying irritability. There was no impairment of thought processing or communication, and there were no delusions or hallucinations. His eye contact and behavior were appropriate. He reported some occasional fleeting suicidal thoughts about every other month although they seemed passive; he stated that he wondered "why he is still here" and sometimes felt as though things do not matter. He reported that he did not feel any suicidal thoughts and had no intent to act on it, as he would not want to do that to his family. He denied any homicidal thinking. The examiner found no significant memory troubles, although the Veteran reported some mild short-term memory difficulties, such as forgetting where he placed things or what he intended to get on an errand; he remembered his medicines and his bills. No obsessive-compulsive behavior was noted. His speech was slow and slightly mumbling at times; he gave generally brief responses with minimal elaboration. He reported a history of panic attacks every month or two. The Veteran reported that his medicines reduced the severity of his depressed mood although he would occasionally still cry and feel sad with low interest and motivation. He reported frequently feeling nervous and tense when out in public and he often felt irritable, although he reported adequate impulse control with no significantly severe anger outbursts. He reported some sleep disturbances including middle insomnia that interrupted his sleep. The March 2008 VA examiner noted the Veteran's reports of nightmares three to four times per week, intrusive memories just about every day, certain things triggering negative upsetting memories for him, avoidance symptoms, limited social interactions and leisure pursuits, a high degree of hypervigilance, feelings of irritability and being easily frustrated and angered, a hyperstartle response to loud sudden noises, poor concentration, and sleep problems. The examiner assigned a GAF score of 52 for the Veteran's PTSD. On August 2008 VA treatment, the Veteran continued to experience periods of increased irritability and intermittent nightmares, but felt that his prescribed medications had been helpful. There was no evidence of persistent or progressive dysphoria, hopelessness, helplessness, worthlessness, or exaggerated guilt. His appetite, daytime energy level, and sleep remained stable. There was no evidence of suicidal or homicidal ideation, intent or plan. The treating physician opined that although the Veteran's PTSD symptoms clearly persisted, they had improved significantly with medication. There were no prominent psychotic symptoms, substance abuse, or cognitive deficits. On November 2008 VA treatment, the Veteran reported an increase in nightmares over the previous week, stating that he was involved in particularly heavy fighting in Vietnam around that time of the year and throughout much of the holiday season; he reported that it was traditionally a difficult time of the year for him. Despite increased PTSD symptoms, he had not experienced a prominent increase in dysphoria, and there was no current suicidal or homicidal ideation, intent, or plan. There were no prominent feelings of hopelessness, helplessness, worthlessness, or exaggerated guilt. His sleep was a bit more disrupted with nightmares and his daytime energy levels were a bit lower. He reported continued mild short term memory problems, likely due to difficulties with concentration. Based on these findings, the December 2008 rating decision on appeal continued a 50 percent rating for the Veteran's PTSD. On April 2009 VA treatment, the Veteran noted that his nightmares persisted and occurred approximately every other night. His symptoms of hypervigilance, exaggerated startle, daytime irritability, and anxiety persisted but had improved somewhat with medication. There was no evidence of progressive dysphoria, though the Veteran reported he was grieving the loss of a close friend's son, which brought back many memories of his own daughter who died many years earlier. He reported that his sons and grandchildren had been major supports and had been very helpful as he processed his grief. He reported chronic intermittent suicidal thoughts but had no intent or plan; his suicidal thoughts had not increased in frequency or severity recently. He appeared very committed to his family and his affect brightened considerably when discussing them. Intermittent insomnia persisted but was improved with medication. The treating physician noted that the Veteran had good family and friend support at home. At a May 2009 Decision Review Officer hearing, the Veteran testified that he had nightmares from which he woke up sweaty and tired, and he got two to two and a half hours of sleep per night on average. He attempted to nap but slept fitfully then as well. He testified to having flashbacks once every month to three months as well as hyperstartle response, and panic attacks approximately twice per week. He testified that he felt more depressed despite being on medication. He testified that he had increasingly frequent suicidal thoughts. He testified that he saw his two sons every now and then. He did not engage in social activities and had very little interaction with others. He testified that he would hear a noise at night and patrol through each room of his house with a gun. He testified that his memory and concentration had worsened, and he would become lost driving in unfamiliar areas. He testified that his sister and niece would come over to bring him food, and his family was always checking up on him. He had a couple of good friends who would take him out to eat, although he would not go out by himself. On December 2009 VA treatment, the Veteran's PTSD symptoms continued with intermittent periods of increased anxiety and irritability, as well as occasional nightmares, hypervigilance, and exaggerated startle reflex; however, the symptoms were significantly improved with medication. He reported that his sleep was interrupted on some nights, and that he slept well at other times. He reported that his spirits had been good and there was no evidence of persistent or progressive dysphoria. There were no prominent feelings of hopelessness, helplessness, worthlessness, or exaggerated guilt. He denied any suicidal or homicidal ideation and there was no intent or plan. His appetite and daytime energy level remained stable, and there were no psychotic symptoms or prominent cognitive deficits. On June 2010 VA treatment, the Veteran reported intermittent nightmares three to four nights per week, hypervigilance, exaggerated startle, and daytime anxiety, although he was noted to benefit significantly from his medications. He noted that his symptoms worsened somewhat around Memorial Day and Independence Day but he cited his family and his girlfriend as significant mitigating factors. He felt that his one year relationship with his girlfriend was going very well, as she helped considerably with distracting him from his intrusive memories and depressive feelings. His symptoms of depression were intermittent and fluctuating with his PTSD symptoms. The Veteran reported that he was looking forward to seeing his grandchildren again and he was very proud of his two adult sons for their accomplishments as well. On January 2011 VA treatment, the Veteran presented in good spirits but reported that he continued to have intermittent nightmares and exaggerated startle as well as hypervigilance. He believed his medications had been helpful and he was sleeping much better at night, although some residual PTSD symptoms persisted. There was no evidence of persistent or progressive dysphoria, and his affect was bright. He reported good relationships with his girlfriend, his sons, and his grandchildren, as well as his father and brother. He was future-thinking and was enjoying activities in life. On November 2011 VA examination, the Veteran was noted to be taking the same medications of Imipramine and Xanax; the examiner noted that, although the Veteran continued to have some PTSD symptoms, the medications were consistently reported to be helping. The examiner noted a September 2011 treatment record in which the treating physician opined that the medications were helping considerably though the Veteran was having some recent increased symptoms and stress in his life, as well as a May 2011 treatment record in which the Veteran was noted to be in good spirits and functioning quite well. On examination, the Veteran reported that he stopped working in approximately 1979 due to his physical health problems; the examiner did not see any evidence that the Veteran's current level of PTSD symptoms, which appeared to be relatively stable, would prohibit any gainful employment. The Veteran reported that he lived with his girlfriend of about three years, and he got along fine with her two young sons, as well as his two grown sons and two granddaughters who were nearby; he also got along with his father and brother who were also nearby. He reported having a couple of friends who would visit him at times to watch sports or go fishing or out to eat. He occasionally went out to do errands but preferred that his girlfriend do so because he had more anxiety in crowds due to his vigilance. He preferred to stay home, spending time with his girlfriend's young son, watching television, or occasionally napping. He denied any significant substance abuse problems or any drug use. He denied any violent or assaultive behavior or suicide attempts. On mental status examination, the Veteran's affect ranged from mildly restricted to within normal limits; he was euthymic on examination. There was no impairment of thought processing or communication, and there were no delusions or hallucinations. His eye contact and behavior were appropriate. He denied any suicidal or homicidal thinking. His memory appeared grossly intact, although he reported occasional memory lapses; he remembered important things like medications and bills. His speech was within normal limits. He reported occasional panic attacks, approximately three times per year, as well as periodic anxiety especially when exposed to crowds. He denied any significant problems with excessively low, sad, or depressed mood, stating that his mood was generally "in the middle". He denied any impulse control difficulties or severe anger outbursts. His sleep was mildly impaired, and he estimated getting 5 to 6 hours per night. The examiner assigned a GAF score of 55 for the Veteran's PTSD and opined that he was relatively stable overall. On February 2012 VA treatment, the Veteran was in reasonably good spirits, noting that the pain from his arthritis during the winter months caused sleep problems and he was typically slightly more dysphoric; however, he noted that he was no worse than in previous winters. He reported that he was enthusiastic about traveling to see his grandson in a wrestling tournament the following month, and he was considering a trip to Nags Head with his girlfriend that summer. There was no evidence of a progressive dysphoric state, and the Veteran's appetite and daytime energy level had remained stable. He reported that he was sleeping fairly well with his medications, which had also improved his PTSD symptoms. There was no evidence of psychosis, and he denied any suicidal thoughts or homicidal ideation. On June 2012 VA treatment, the Veteran reported an increase in his nightmares, hypervigilance, and exaggerated startle reflex as well as his daytime anxiety symptoms. He reported that the symptoms had fluctuated through the years, and his current state was well within his normal range; he believed that the recent Memorial Day holiday and the upcoming Independence Day holiday played some role in the increase. Despite his increased PTSD symptoms, the Veteran's affect was bright and he was very optimistic when talking about his family; he was caring for his grandson on an intermittent basis, which he enjoyed, and he had a new dog with which he enjoyed playing. He reported that, although his daytime energy level was chronically low, he had been able to maintain his typical daily routine overall. He reported no recent suicidal or homicidal ideation and there was no intent or plan. There had been no recent psychotic symptoms. In a July 2012 statement, the Veteran's representative stated that a number of recent personal losses had reactivated the Veteran's memory of incidents relating to his military service, and the Veteran had indicated that these events had aggravated his condition and made him more depressed; the representative stated that the Veteran's only social life is when his family stops by to check on him, and outside of his counselor the Veteran does not communicate with many people at all. At the August 2012 Travel Board hearing, the Veteran testified that he sought VA treatment every two to three months. He testified that he experienced symptoms of sleepwalking, night sweats, insomnia, nightmares, and fighting in his sleep, as well as a constant nervousness when awake; he reported going fishing once in a while with his girlfriend or his sons or going out to eat with his girlfriend. He reported taking medications for PTSD that made him feel tired and lacking energy to do anything but stay around the house most of the time. On September 2012 VA treatment, the Veteran reported that overall he had changed very little since the previous visit. He continued to experience intermittent nightmares, hypervigilance, exaggerated startle, and daytime anxiety/irritability symptoms, although the symptoms improved considerably with the combination of Imipramine and Xanax. Overall, he did not think his PTSD symptoms were significantly worse than they had been in recent years. He had relatively brief fluctuating periods of dysphoria, often related to increased pain or other life stressors, and with most episodes lasting less than one day. There had been no recent suicidal or homicidal ideation and no intent or plan. His sleep continued to be somewhat erratic but was improved with Benadryl, although nightmares did disrupt his sleep on an intermittent basis. In October 2012, the Board remanded the matter for a contemporaneous VA examination and to obtain outstanding VA treatment records. On December 5, 2012 VA examination, the Veteran reported that he continued to live with his girlfriend and her young son and things were going somewhat well with his relationship. He reported having good relationships with both of his adult sons, he had four grandchildren and one great-grandchild, and he had one or two friends he would get together with to watch sports or occasionally go out to dinner. He reported that his mood was labile; he felt depressed sometimes and okay other times, although he got no relief from his anxiety. His symptoms were noted to include depressed mood, anxiety, panic attacks more than once per week, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), impaired judgment, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, and suicidal ideation. The examiner opined that the Veteran was not capable of managing his financial affairs, and his live-in girlfriend of 4 years helped him manage his finances due to the arthritis in his hands. The examiner opined that the Veteran's PTSD is at a moderate severity level. The examiner assigned a GAF score of 55 for the diagnosis of PTSD. Based on these findings, a February 2013 rating decision granted a 70 percent rating for PTSD, effective December 5, 2012 (the date of the VA examination). In an April 2013 addendum opinion, the December 2012 VA examiner opined that the Veteran's PTSD symptoms resulted in occupational and social impairment with reduced reliability and productivity. The examiner noted that the Veteran reported being unable to work because of the sedating effects of all the medications he takes, including Xanax and Benadryl (both of which can cause drowsiness) to treat symptoms of PTSD. The examiner noted that he also takes Tegretol for seizure disorder and Oxycodone for pain, both of which can also cause drowsiness. The examiner clarified that it is not the Veteran's PTSD which renders him unable to manage his finances independently, but rather the arthritis in his hands. Additional VA treatment records throughout the appeal period show symptomatology largely similar to that found on the VA examinations described above. The reports of the VA examinations, the VA treatment records, lay statements, and the Veteran's testimony, overall, provide evidence against his claim, as they do not show that prior to December 5, 2012, symptoms of his PTSD produced deficiencies in most areas, so as to meet, or approximate, the criteria for a 70 percent rating. He did not display obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships, nor did he exhibit any other unlisted (in the rating criteria) symptoms of similar gravity. The treatment records and examinations from that time revealed no impairment of thought processes or content. The next higher, 70 percent, rating requires occupational and social impairment with deficiencies in most areas. Here, deficiencies in most areas simply were not shown prior to December 5, 2012. Continuing the analysis, the reports of the VA examinations, treatment records, lay statement, and the Veteran's testimony, overall, do not show the Veteran's PTSD to have been of such severity as to warrant a 100 percent schedular rating from December 5, 2012. There is no evidence (or even allegation) of symptoms such 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; or memory loss for names of his close relatives, own occupation, or own name. The treatment records and examinations consistently show appropriate thought processes and content and appropriate behavior. There were very infrequent reports of [only] passive suicidal ideation; and no delusions or hallucinations were observed on treatment or examination. While the observations by the VA examiners and treatment providers suggest that the Veteran has increasingly limited social relationships, such impairment is clearly encompassed by the criteria for a 70 percent rating (which contemplate deficiencies in most areas). The disability picture presented is not one consistent with the criteria for a schedular 100 percent rating. Consequently, such rating for PTSD is not warranted at any time. The Board notes that the Veteran's GAF scores throughout the appeal period have ranged from 52 to 55, consistent with moderate ranging to severe symptoms (on which the 50 percent, then 70 percent ratings are based). Consequently, the GAF scores (of themselves) do not provide a separate basis for increasing the ratings. The Board notes the lay statements submitted by the Veteran in support of this claim. Those statements detail the types of problems that result from the Veteran's symptoms of PTSD. The levels of functioning impairment described by the Veteran are encompassed by the criteria for the 50 percent and 70 percent ratings assigned for the periods of time on appeal; thus the lay statements do not support the assignment of higher schedular ratings. All symptoms of the Veteran's PTSD are encompassed by the schedular criteria (outlined above), and those criteria are therefore not inadequate. Hence, referral of this case to the Compensation Service Director for consideration of an extraschedular rating is not warranted. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the Veteran has repeatedly stated that he stopped working in 1979 due to physical health problems and not psychiatric disability. Examination reports likewise reflect that his impaired functioning (including in handling financial matters) results from physical (not psychiatric) problems. The matter of entitlement to a total rating based on individual unemployability is not raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Ratings for PTSD with depression in excess of 50 percent prior to December 5, 2012 and/or in excess of 70 percent from that date are denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs