Citation Nr: 1330998 Decision Date: 09/26/13 Archive Date: 09/30/13 DOCKET NO. 10-46 182 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from June 1969 to March 1972 and from April 1973 to September 1978. He is in receipt of several citations that denote participation in combat. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which granted a 30 percent rating for PTSD effective June 10, 2009. The Veteran presented testimony at a personal hearing before the undersigned Veterans Law Judge in August 2011. A transcript is of record. Additional evidence has been submitted since the RO certified the Veteran's claim to the Board. The additional evidence consists entirely of statements made by the Veteran to his State Senator that he wanted associated with his claims folder. These statements, some of which are accompanied by Internet news articles about the backlog of claims facing VA, are an attempt by the Veteran to voice his displeasure at the amount of time that it has taken to adjudicate his claim. As they are not pertinent to the issue on appeal, the evidence need not be remanded to the agency of original jurisdiction (AOJ). See 38 C.F.R. § 20.1304 (2012). The record before the Board consists of paper claims files and an electronic file known as Virtual VA. FINDING OF FACT The Veteran's PTSD has caused occupational and social impairment with reduced reliability and productivity throughout the appeal period. CONCLUSION OF LAW The criteria for a rating of 50 percent, and not higher, for service-connected PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION VA's duties to notify and assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100%" based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO provided the appellant pre-adjudication notice by a letter dated in December 2008, and additional notice by an October 2010 statement of the case. The claim was readjudicated in an April 2011 supplemental SOC (SSOC). Mayfield, 444 F.3d at 1333. VA has obtained service treatment records; assisted the appellant in obtaining evidence, to include VA treatment records; afforded the appellant psychiatric examinations; obtained medical opinions as to the severity of his disability; and afforded the appellant the opportunity to give testimony. All known and available records relevant to the issue on appeal have been obtained and associated with the appellant's claims file, and the appellant has not contended otherwise. Moreover, the record shows that the appellant was represented by a Veteran's Service Organization throughout the adjudication of the claim. Overton v. Nicholson, 20 Vet. App. 427 (2006). VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Increased rating Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Separate rating codes identify various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. See generally 38 C.F.R. §§ 4.1, 4.2 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When service connection has been in effect for many years, the primary concern for the Board is the current level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Yet, the relevant temporal focus for adjudicating an increased rating claim is on the evidence establishing the state of the disability from the time period one year before the claim was filed until a final decision is issued. Hart v. Mansfield, 21 Vet. App. 505 (2007). Thus, staged ratings may be assigned if the severity of the disability changes during the relevant rating period. Service connection for PTSD was originally granted pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, with a noncompensable rating effective July 24, 2008. See September 2008 rating decision. The rating was subsequently increased to 10 percent effective December 11, 2008, in a February 2009 rating decision. The Veteran filed a request for reconsideration and in the January 2010 rating decision that is the subject of the current appeal, the rating assigned for PTSD was increased to 30 percent effective June 10, 2009. The effective date assigned by the RO was based on a private treatment record dated June 10, 2009, that supported the assignment of a 30 percent rating. The Veteran formalized an appeal of the January 2010 rating decision by first submitting a June 2010 notice of disagreement and thereafter filing a November 2010 VA Form 9. The Board notes that the June 2010 notice of disagreement was not timely as to the February 2009 rating decision. The Board also notes that the request for reconsideration was apparently misplaced by the RO. When asked to reproduce it, the Veteran's representative resubmitted a document dated July 22, 2009. See November 2009 submission. Given the foregoing, the Board will determine whether the Veteran is entitled to a rating in excess of 30 percent as of July 22, 2008. See Francisco, 7 Vet. App. at 58; Hart, 21 Vet. App. at 509-510. The Veteran testified as to the symptomatology associated with his PTSD in August 2011. He reported that he was working but had quit several jobs throughout the years. The Veteran indicated that he had trouble with relationships, as evidenced by his four marriages. He also reported withdrawal, nervousness, jumpiness, hypervigilance, short term memory loss, being easily distracted, avoidance of crowds, sleep impairment, irritability, difficulty concentrating, and feeling that home is his comfort zone. One of the Veteran's ex-wives has submitted a statement describing some of the Veteran's symptoms during the years they were married, namely between 1999 and 2007. She reported that the Veteran demonstrated certain behaviors that were both repetitive and somewhat predictable; that he would skip from one idea to the next while in conversation without finishing the initial thought; that his voice would become excitable or agitated when talking about his military experience; that he repeated the same stories with almost identical words; that he would often withdraw during family dinners, or during times when they were alone together, and go into his own little world, becoming uncommunicative; that at times, the withdrawn/depressed state would go on for more than a few days; that he watched military programs on television repetitively; that everything in the Veteran's life related back to his combat experience and that he did not shy away from discussing it; that he liked things orderly and with minimal decoration; that he was unwilling to discuss their relationship during one visit to a psychologist; and that he could become fixated on certain things, both mentally and in his verbalization of it. See July 2010 letter from D.G. Pursuant to the General Rating Formula for Mental Disorders, a 30 percent evaluation is warranted where the disorder is manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013) A 50 percent evaluation 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 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. Id. A 70 percent evaluation contemplates occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. Id. Lastly, a 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting 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 name. Id. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, 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, are to be considered. See 38 C.F.R. § 4.126. 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, then the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Federal Circuit has embraced the Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 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. 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). A Global Assessment of Functioning (GAF) rating 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 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994) (DSM-IV). A GAF of 31 to 40 is defined as some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF of 41 to 50 is defined as 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 GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 61 to 70 is defined as 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, has some meaningful interpersonal relationships. A GAF score generally reflects an examiner's finding as to the Veteran's functioning score on that day and, like an examiner's assessment of the severity of a condition, is not dispositive. Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2012). Prior to discussing specific evidence in this case, the Board notes that it has reviewed all the evidence in the Veteran's paper and Virtual claims files and although it has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence); see also Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (the Board is presumed to have considered all evidence presented in the record; it is not required to specifically discuss every piece of evidence). The Veteran first sought psychiatric treatment through VA in June 2008, at which time he reported "I am here about this PTSD. I want to get checked for it. I am a member of the VFW and he told me about this place and said I ought to come here." The Veteran reported getting maybe four to five hours of sleep per night and not having any friends. He indicated he was a loner and had joined the Veterans of Foreign Wars (VFW) so that he had someone to talk to. He reported that it seemed "those guys are the only ones I can talk to because most of my conversation is about my military time even thought it was a long time ago." The Veteran indicated that his recent memory was not good. He reported four divorces and not having much contact with his three children. The Veteran reported that after service, he worked for Duke Power for almost 20 years before retiring from there. He was working as a truck driver for Thomas Concrete at the time he sought treatment. The Veteran indicated that he avoided people, was hesitant to voice his opinion because he might get angry, was irritable and nervous, was unable to sustain a relationship, and had insomnia. Although the Veteran indicated he had friends at the VFW, when questioned, he was unable to name friends or family who emotionally support him. The Veteran presented with anxiety, recurrent depression, insomnia, cognitive changes, and difficulty coping with illness in the form of issues with relationships. His appearance was neat and clean, eye contact was good, kinetics were decreased, verbalization was rapid, mood/affect was depressed and anxious, sensorium was normal in terms of alertness, and the Veteran was oriented to time, place, person and situation. Concentration was good, recent memory was fair, and remote memory was good. The Veteran denied suicidal and homicidal ideation with and without plan. A GAF score of 50 was assigned. See mental health initial treatment plan note. The Veteran was seen for 45 to 50 minutes of treatment that same month, at which time he reported a sense of detachment from others, lack of concentration, short term memory loss, and lack of interest and participation in life. Significant issues, symptoms or complaints were "I have been married four times. My last wife and I are seeing each other again. I want a relationship but I don't pick the ones or something's wrong with me. I don't seem to have any interest in things anymore, most things they seem petty. The thing I most worry about is my memory, it seems like when someone tells me something, I forget it because I am not listening or it's not important to me. I feel like I am getting 'old timers' (Alzheimer's). I really want to know if I have PTSD because it would help explain a lot of things about my life since Vietnam." Mental status examination revealed that the Veteran was neatly dressed with good hygiene. Affect was blunt until he began speaking of his war experiences, at which time it became animated and expansive. Speech was rapid. Mood was depressed until he engaged in war stories. He brought a yearbook and gave an extensive history of the people, places, feelings and experiences from Vietnam in 1969. Thought process was racing and tangential. The Veteran was able to relate the smallest detail of his war experiences and people from that time, but had trouble with memory and concentration with day to day activities. The assessment was that the Veteran exhibited rapid cycling in mood and affect based on if he is explaining something related to his war experience or not. He was not interested in pills as he felt they "will mess you up," though he endorsed depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. He also had trouble relating to people and general isolation. See June 2008 mental health note. The Veteran was seen in July 2008 for 20-30 minutes of individual therapy. Mental status revealed that he was alert, oriented, calm, and cooperative for the interview. Behavior was calm, speech was at a normal rate and tone, affect was full-ranged, and mood was euthymic. Thought process was linear and goal-directed and there were no hallucinations or delusions. The Veteran denied homicidal or suicidal ideation, plant or intent. He complained of some short term memory loss but insight and judgment were reported to be good. The Veteran reported that he and his ex-wife had gone on vacation to Florida together over the Fourth of July. He noted that he was back in a relationship with his ex but was taking it one day at a time. He continued to attend VFW meetings and continued to work, taking a "cool hand Luke" attitude and is able to do the job without getting upset. The Veteran did not feel the need to return for counseling at that time but was interested in the psychiatrist evaluating him for PTSD and possible dementia. He reported sleep disturbance (only getting five or six hours a night); a sense of detachment (does not want to be in crowds or go to groups; still prefers being alone and watching television); lack of concentration; and short term memory loss. An Axis I diagnosis of PTSD was made. See mental health note. Another July 2008 mental health record reveals that the Veteran was seen alone for medication evaluation. He was not interested in medical management of his PTSD. He reported rare nightmares and denied flashbacks and exaggerated startle. He reported working as a truck driver and was functioning well socially and at work. He had no major complaints. Mental status examination revealed that he was alert, attending and verbally interactive. Mood was euthymic and he had full range of affect. Speech was spontaneous with normal rate and tone. Sleep and appetite were good and he had increased energy and interests. Thought process was linear, goal-directed, abstract and coherent. There were no psychotic thoughts, delusional thoughts, or homicidal or suicidal thoughts, plans or risk present. A diagnosis of PTSD was made and a GAF score of 65 was assigned. See mental health attending note. The Veteran underwent a VA initial examination for PTSD in August 2008, at which time his claims folder was available for review. When asked to describe his emotional difficulties, the Veteran stated "well I really never heard of this PTSD stuff until I went to the Purple Heart Chapter of the Veterans of Foreign Wars." He stated that he began spending time with other Veterans and they talked about their symptoms and he found that he was having similar symptoms. The Veteran reported difficulty maintaining sleep and difficulty going back to sleep if he awakens during the night. He denied anxiety or sweating when he did wake up. He also denied nightmares and flashbacks, but did report almost-daily intrusive thoughts. Triggers were helicopters and aircraft. The Veteran reported that he does not like to go into crowds and prefers being off by himself. He prefers watching television and not bothering with other people. He indicated he went to the Veterans of Foreign Wars "frequently" because he feels comfortable around Veterans. He especially likes other Purple Heart recipients. The Veteran reported going out to restaurants and mild difficulty with anger control. He denied symptoms of anxiety and reported that he typically felt safe at home. He reported being startled by noise and touch. The Veteran indicated that he watches the military and history channel "most of the time" and did have conversations with other Veterans about his experiences. The Veteran denied any inpatient treatment and had recently been diagnosed but no treatment had been initiated. He indicated that he had been married four times and divorced four times. When asked the reason for that, he stated "I always thought it was the girl but now I'm starting to realize that it was me with my anger and isolation." He was living by himself and denied any current legal charges or arrests. He reported only drinking occasionally and denied abusing alcohol or using drugs. In regards to employment, the Veteran reported working for Duke Power for 20 years in their nuclear division and then leaving on early retirement. He then drove a truck for 10 years. The examiner indicated he was capable of performing his activities of daily living and did this routinely and independently. Mental status examination revealed that the Veteran was alert and oriented to personal information and place. Temporal orientation was normal and he provided an accurate history. Insight was adequate, affect was normal and response latencies were normal. The Veteran demonstrated adequate attention and was not distractible. Spontaneous speech was fluent, grammatic and free of paraphasias. Immediate, recent and remote memory was all within normal limits. During the interview, he was noted to be logical and goal directed. He reported intermittent dysphoria but denied both suicidal and homicidal ideation and plan. There was no evidence of disorder in thought process or content and he made good eye contact. There was also no grandiosity, pressured speech, motor over activity, restlessness, tics, or odd motor behaviors noted. An Axis I diagnosis of mild PTSD was made and a GAF score of 65 was assigned. The examiner reported that he presented with symptoms of mild PTSD and that his presentation was consistent with that noted in his claims file; that his psychiatric presentation was resulting in a minimal degree of impairment in social functioning, and no impairment in occupational functioning; that his overall level of disability was minimal; and that he was competent to manage his own funds. The Veteran was seen for 20 to 30 minutes of individual therapy in November 2008, at which time it was noted that he was upset with the evaluation of his PTSD. The examiner reported that the Veteran's session notes were reviewed together, including that one where PTSD was diagnosed based on symptoms reported. The examiner reported that she distinctly remembered the Veteran and how she had encouraged him to attend PTSD group, to which the Veteran responded "well my memory is not that good and I had heard that the groups were not made up of combat veterans and I did not want to meet with anyone that did not go thru what I went thru." Relevant mental status examination and other objective findings reveal that the Veteran was alert and oriented times three. He denied suicidal and homicidal ideation and also denied audio or visual hallucinations. VA treatment records reveal that the Veteran thereafter attended group therapy on one occasion in November 2008 and on three occasions in December 2008. The Veteran received mental health treatment in January 2009, at which time his strengths, to include, in pertinent part, capacity for empathy, impulse control, intelligence, judgment, and frustration tolerance were noted. He noted problems with sleep disturbance, isolation and depression. See mental health initial treatment note. The Veteran also received 30 minutes of individual supportive psychotherapy in January 2009, at which time he reported continued poor sleep, depression and isolation. Chief stressors included failed relationships as he had had four failed marriages. He reportedly enjoyed church activities and going to church. Mental status examination revealed that he was oriented time three and was no suicidal or psychotic. He was very verbal about his military experiences and how they affected him. VA treatment records reveal that the Veteran attended group therapy twice in January 2009. The Veteran underwent a VA review examination for PTSD in February 2009. When asked to describe his emotional difficulties, the Veteran stated "well, I just can't seem to relate to people. I have been married four times. Now all I do is get up, go to work and come home. I have trouble sleeping." In regards to difficulty sleeping, he reported getting five to six hours per night, but waking up every couple of hours. He also indicated that he would stay up late despite being tired in an effort to assist sleep. When questioned about nightmares, the Veteran stated "I don't know if you will call them nightmares." He did not report any sorts of dreams, just that he would wake up and have difficulty getting back to sleep. He denied flashbacks. Regarding intrusive thoughts, he stated "all the time." Helicopters were triggers and he stated that "I feel like I am Radar on MASH," explaining that is because he hears approaching helicopters before anyone around him seems to. The Veteran reported that he does not like crowds and stays to himself, preferring to stay in his own and "not deal with people." He did report going frequently to the VFW and associating with Vietnam combat Veterans. He also reported eating out frequently, but has noticed that he goes when the restaurants are not crowded. He also shops and has a routine where he will go to the food stores on Sunday. Outside of the VFW, he does not have any friends. The Veteran reported mild anger control difficulties. He denied anxiety outside of being in public. He reported mild to moderate dysphoria. He indicated feeling safe at home, stating "it is my fortress of solitude," but reported startle response to both noise and touch. In regard to watching news programs about war and movies about war, he stated he watches "as much as I can." The Veteran denied any inpatient treatment and reported receiving treatment since December 2008. The Veteran reported being married and divorced four times. The last divorce was two years prior. He was living by himself and was not in any current relationship. He denied any current legal charges or arrests. He indicated that he occasionally drank alcohol and did not describe any difficulty with alcohol use. He denied drug use. The Veteran reported working for Duke Power for 20 years and taking early retirement. He had started driving a truck and had had seven jobs as a truck driver, three with the same company. He reported "I get mad and quit." He denied any problems with coworkers or job performance. He also started that he never missed work. The Veteran was capable of performing activities of daily living and could do them routinely and independently. Mental status examination in February 2009 revealed that the Veteran was alert and oriented to personal information and place. Temporal orientation was normal. He provided an accurate history and insight was described as adequate. Affect and response latencies were normal. The Veteran demonstrated adequate attention and was not distractible. Spontaneous speech was fluent, grammatic and free of paraphasias. Immediate, recent and remote memory was all within normal limits. During the interview, the Veteran was noted to be logical and goal directed. He reported mild to moderate dysphoria, but no other symptoms of depression. He denied suicidal and homicidal ideation and plan and there was no evidence of disorder in thought process or content. He made good eye contact, but mild pressured speech and mild restlessness were noted. There was no irritability or grandiosity noted. An Axis I diagnosis of mild, chronic PTSD was made and a GAF score of 60 was assigned. The examiner reported that the Veteran presented a consistent history and presentation and that he was currently experiencing a mild degree of impairment in social functioning and a minimal degree of impairment in occupational functioning. His overall level of disability was mild and he was competent to manage his funds. The Veteran received 30 minutes of individual supportive psychotherapy in February 2009, at which time he reported continuing to have a stressful job as a concrete truck driver and frustration with the VA system. He told of his memories of incidents in Vietnam. The Veteran reported that although trust is an issue, he would like to have companionship and would like to become more stable with his mood. Mental status examination revealed that he was oriented times three and was not suicidal or psychotic. He continued to be verbal about his Vietnam experiences and failed relationships. See mental health note. A GAF score of 50 was assigned. See February 2009 addendum. VA treatment records reveal that the Veteran attended group therapy twice in February 2009. The Veteran was seen for 20 to 30 minutes of mental health treatment in April 2009. He reported that he had been transferred to a different plant of Thomas Concrete and was less able to get to group therapy and individual appointments. He endorsed difficulty sleeping with frequent night time awakening. He was frustrated "dealing with the Dorn VA." The Veteran reported that he was functional on his job and had dreams that awaken him, but could not recall their content. He reported being hypervigilant, indicating that his co-workers come up behind him and tap him, thinking that it is funny to do so as he reacts intensely. The Veteran gave a history of long standing interpersonal problems, to include being married four times and having seven different jobs as a result of getting mad and walking off. He denied depressive symptoms such as crying, a sense of guilt, and he indicated that his appetite and levels of interest and concentration were good. Mental status examination revealed that he was alert and oriented times four but withdrawn in no apparent distress. His attire was clean and casual and appropriate to season and situation. Hygiene and grooming were good. His behavior was cooperative, polite and pleasant and speech was normal in all parameters. Mood was euthymic and affect was full, congruent and appropriate. Thought processes were clear, linear, logical and goal-oriented. There was no evidence of psychotic symptoms, specifically no audio or visual hallucinations and no paranoia, ideas of reference, delusions or grandiosity. Insight and judgment were fair; short and long term memory was intact with grossly average intelligence. An Axis I diagnosis of PTSD was made and a GAF score of 60 was assigned. See mental health note. VA treatment records reveal that the Veteran attended group therapy once in May 2009. A May 2009 suicide risk assessment reveals that the Veteran denied suicidal thoughts and any attempt at suicide. He also did not feel hopeless and did not engage in behaviors without thinking things through or considering the consequences. The Veteran was examined by a private physician at Goldsboro Psychiatric Clinic in June 2009. He reported being divorced from his fourth wife for three years and having worked at Duke as a mechanical maintenance man for 20 years after service. For the past 11 years he had been a cement truck driver. The Veteran reported seldom nightmares but waking up in a panicked sweat that lasts 10 to 15 minutes. He had flashbacks three to four times a week. He averaged only two to three hours of sleep per night. The Veteran also reported intrusive thoughts, easy startle, hypervigilance, and intolerance to anyone standing behind him. He rarely socialized and only with family. His recent memory was severely impaired so that he could not remember what he reads and gets lost when traveling. His working memory was 75 percent impaired. Anger, sadness and fear come upon him without his understanding why 10 percent of the time, which the examiner noted indicates a dysfunctional prefrontal cortex. The Veteran reported feeling depressed 50 percent of the time with no energy and little interest in things. He angered and agitated easily. The examiner reported that because of his PTSD, the Veteran is moderately compromised in his ability to sustain social relationships and was moderately compromised in his ability to sustain work relationships. An Axis I diagnosis of chronic PTSD was made and a GAF score of 45 was assigned. The Veteran received mental health treatment in June 2009, at which time his strengths, to include, in pertinent part, capacity for empathy, impulse control, intelligence, judgment, and frustration tolerance were noted. He noted problems with sleep disturbance, isolation and depression. See mental health initial treatment note. A suicide screen was negative. See June 2009 addendum. The Veteran also received 30 minutes of individual supportive psychotherapy in June 2009, at which time he reported that he was still struggling with the VA benefits issue and family issues. He also still got easily frustrated and talked about how his Vietnam issues had affected him. He reported keeping in contact with other Veterans. The Veteran indicated he wanted to continue working if he could and to continue keeping in contact with other Veterans. He also enjoyed doing some chores. Mental status examination revealed that he was oriented times three and not suicidal or homicidal. See mental health note. Also in June 2009, the Veteran was seen by a mental health nurse practitioner for 20 minutes for medication review. He reported infrequent nightmares but complained of thinking nonstop about Vietnam. He also reported hypervigilance, high startle response, social isolation and jumping at loud noises. He indicated he had been divorced four times. The Veteran's speech was slightly pressured but he was able to slow with some direction and structure. The complained of impaired recent memory and reported sleeping six to seven hours per night. He drank about two drinks per week and denied suicidal or homicidal ideation. There were no psychotic symptoms. A GAF score of 60 was assigned. The Veteran received 30 minutes of individual supportive psychotherapy in July 2009, at which time he reported that he was not sure pills were helping with sleep. He described an up and down mood and tended to isolate himself. He was still able to drive a truck for his employer but reported that he was trusting people "less and less." The Veteran reported that he was not able to attend group therapy due to his work schedule. Mental status examination revealed that he was oriented time three and not suicidal or psychotic. He wanted to understand himself better. See mental health note. A suicide screen was negative and a GAF score of 50 was assigned. See July 2009 addendum. The Veteran received 30 minutes of individual supportive psychotherapy in September 2009, at which time he reported that he had stopped medication a month prior, that he was still driving a truck (though he was concerned about job security), that he still isolated himself, that when under stress he can occasionally feel his blood pressure rise, and that he felt "jerked around by the VA." The Veteran reported becoming more reclusive, but going to church on Sunday, and he indicated that he had to work to support himself and to make child support payments. Mental status examination revealed that he was oriented time three and not suicidal or psychotic. He wanted to understand himself better. See mental health note. A suicide screen was negative. See September 2009 addendum. VA treatment records reveal that the Veteran attended one group therapy session in February 2010. A March 2010 suicide risk assessment reveals that the Veteran denied suicidal thoughts and any attempt at suicide; he also did not feel hopeless and did not engage in behaviors without thinking things through or considering the consequences. The Veteran received mental health treatment in March 2010, at which time his strengths, to include, in pertinent part, capacity for empathy, impulse control, intelligence, judgment, and frustration tolerance were noted and he reported problems with sleep disturbance, anxiety and depression. See mental health initial treatment note. The Veteran was also seen for 30 minutes of cognitive-behavioral psychotherapy in March 2010. He reportedly was still drinking alcohol and had intermittent sleep. He also reported still jumping when someone comes up behind him. The Veteran indicated he felt more calm when he is alone but reported going out of the house and going to the River Rat, which helped his mood. The Veteran indicated he was still working, though he had some job insecurity, and that he did not like driving a truck because he works alone. The Veteran was observed to be frustrated when he talked about the VA system. He was dressed casually in jeans and a baseball cap. He made good eye contact and spoke spontaneously about his Vietnam experiences. He was assessed to have insomnia, anxiety and depression, still startling easily, and being isolative. A GAF score of 55 was assigned. See mental health note. VA treatment records reveal that the Veteran attended group therapy one time both in May 2010 and June 2010. He received 30 minutes of cognitive-behavioral psychotherapy in June 2010. The Veteran reported that as long as he is working or involved in an activity, his mood is better. He indicated that he still struggled with sleep and drank alcohol but was careful about how much he drinks as he did not want to get a DUI since he was working as a truck driver. The Veteran indicated that he felt more calm when he was by himself. He had gotten more involved in the Purple Heart chapter in his area and they did charitable and fund-raising activities. The Veteran was observed to be intense. He was dressed casually in a Purple Heart shirt and hat. Eye contact was good and he spoke spontaneously about his Vietnam experiences. The Veteran was assessed to be benefitting from his involvement in Purple Heart and his contact with other Veterans. He was also noted to be developing insight to his symptoms and stressors. Mental status examination revealed that he was oriented times three and was not suicidal or psychotic. A GAF score of 55 was assigned. See mental health individual psychotherapy note. A suicide screen was negative. See June 2010 addendum. The Veteran underwent another VA review examination for PTSD in August 2010, at which time his claims folder was available for review. Only pertinent findings will be discussed. The Veteran reported receiving treatment through VA and not receiving any medication. He indicated problems with appointments and cancelled appointments. He also reported involvement with counseling and group therapy. He denied a history of hospitalization for PTSD. The Veteran reported difficulty with his sleep and described how he tries to stay awake as long as he can. He reported that when he does go to sleep, he is able to fall asleep and has some difficulty maintaining sleep at times. He reported getting about fours of sleep a night on average. He reported having dreams but being unable to recall their content. The Veteran also reported problems with hypervigilance, exaggerated startle response to loud noises, and difficulty in crowds. He reported having intrusive thoughts "all the time." When asked about flashbacks, he described intrusive thoughts rather than actual flashbacks of experiences in Vietnam. The Veteran reported keeping in touch with old service buddies, talking to them on the phone and going to visit them. He also sought out opportunities to become engaged with others regarding his service in Vietnam. The Veteran reported mild difficulty with anger and irritability. He reported that he primarily stayed to himself and did not act out violently. He reported continued use of alcohol but would not specify how often or how much. The Veteran reported mildly depressed mood that depended on certain triggers that remind him of Vietnam. He denied any history of suicide attempts and denied current suicidal or homicidal ideation. He reported some periods of decreased motivation but denied significant problems with anxiety and panic attacks. He reported adequate energy and appetite. The Veteran reported problems with his memory for about 12 years and felt that it was getting worse lately. He described "train of thoughts gets derailed." He indicated that sometimes at home "I can sit and watch T.V. for hours." The Veteran reported having a few friends, but did not see them on a regular basis. He had been a member of the VFW and was going there to drink on a daily basis. He reported that he had become more active in the Purple Heart chapter because they are more service oriented. The examiner noted some mild remission of symptoms due to treatment. The Veteran reported living alone and had been divorced from his fourth wife for about four years. He was not currently in a relationship. The Veteran reported that his friends are primarily those in the service organization and that he had a few others but did not see them often. He primarily spent his time at home watching television. He was able to adequately manage his hygiene, take care of his finances, drive, do basic cooking and cleaning, and ambulate independently. The Veteran was currently employed with Thomas Concrete driving a concrete truck. He reported being employed by Duke for 20 years and taking a buyout while they were downsizing. He then completed his commercial driver's license and will alternate between doing on the road truck driving and working for Thomas Concrete. This is the third time he has worked with Thomas Concrete. He reported seven different jobs in eight years. He reported difficulty with exaggerated startle response on the job, problems with memory, and difficulty getting along with people. The Veteran reported that he liked to work alone. Mental status examination at the time of the August 2010 VA examination revealed that the Veteran was alert and oriented to person, place, day, date and time. Thought process was linear and history was adequate. Affect was mildly blunted and insight was demonstrated. Spontaneous speech was fluent and grammatic and free of paraphasias. Attention and memory were generally within normal limits. The Veteran did not report any overt symptoms of psychosis. He reported occasionally seeing something in his peripheral vision, but denied any current experiences of visual or auditory hallucinations. The Veteran denied a history of suicide attempts and denied any current suicidal or homicidal ideation. An Axis I diagnosis of PTSD was made and a GAF score of 55 was assigned. The examiner noted that the Veteran reported mild remission of symptoms due to treatment, presented with continued symptoms of PTSD, presented with moderate impairment of functioning due to symptoms of PTSD with moderate impairment in both social and occupational functioning, and that he was competent to manage his own funds. A September 2010 mental health attending note reveals that the Veteran had been divorced four times and was living alone. He was a cement truck driver. The Veteran's chief complaint was insomnia, irritability, problems with concentration (cannot remember directions from boss) and social isolation. He reported re-experiencing in the form of nightmares several times a week and intrusive thoughts. Sometimes he wakes up in a start with unremembered dreams and takes approximately 30 minutes to go back to sleep. There were no specific triggers for intrusive thoughts and he was thinking about Vietnam and those killed in action all the time. The Veteran also reported avoidance (socializing and crowds), hypervigilance in the form of being on guard all the time, staying home a lot, anhedonia, detachment from others or finding it hard to get close to people, insomnia, problems with concentration, easy startle response, and irritability. He denied homicidal ideation and though he thought life was not worth living, he had no plans to hurt himself. He felt like he is less than, but was forward looking in terms of his job. In terms of psychosis, the Veteran reported seeing shadows. The examiner indicated that obtaining a complete history was not achieved because of the Veteran's irritability, anxiety and rapport building. Mental status examination revealed that he was alert and irritable. It was noted he kept switching doctors due to changes in psychiatrists in the clinic. There was some motor agitation and speech was pressured but stoppable. Mood was irritable and affect was depressed, with mood congruent to affect. Thought process revealed some looseness of association but there was no psychosis in thought content. In an addendum, a GAF score of 55 was assigned and a suicide screen was noted to be negative. The Veteran attended group therapy once in September 2010. An October 2010 mental health attending note reveals that the Veteran had been divorced four times and did not see his children due to problems with his ex-wife. He was living alone and working as a cement truck driver. The Veteran's chief complaint was insomnia, irritability, problems with concentration (cannot remember directions from boss) and social isolation. He reported re-experiencing in the form of nightmares several times a week and intrusive thoughts. Sometimes he wakes up in a start with unremembered dreams and takes approximately 30 minutes to go back to sleep. There were no specific triggers for intrusive thoughts and he was thinking about Vietnam and those killed in action all the time. The Veteran also reported avoidance (socializing and crowds), hypervigilance in the form of being on guard all the time, staying home a lot, , detachment from others or finding it hard to get close to people, insomnia, problems with concentration, easy startle response, and irritability. He reported being down a lot of the time but denied anhedonia. He did not appear to have a sense of foreshortened future as he tried to take things day to day. In terms of insomnia, the Veteran reported two to three and up to five or six hours of sleep at night if he had only gotten two to three the day before. He felt he could get by on little sleep some days in a row if he kept busy. Appetite was described as easily satiated and snacking a lot here and there. Energy was described as ok unless he is not busy. At work he does what he is supposed to and at home he watches television and does not do other things as it is harder to motivate there. Concentration was low. Psychomotor agitation was noted and the Veteran indicated that he sometimes felt guilty about surviving Vietnam. He denied homicidal ideation and though he thought life was not worth living, he had no plans to hurt himself. He was forward looking in terms of his job. In terms of psychosis, the Veteran reported seeing shadows. The examiner indicated that it was hard to ascertain history for mania or hypomania. The Veteran was reportedly irritable sometimes and denied euphoria, grandiosity or big plans. He had pressured speech sometimes and was distractible. He had racing thoughts and increased psychomotor energy, especially at work. He was not a risk taker. The examiner also noted it was hard to pin down alcohol history. There was no generalized anxiety disorder, social phobia or spontaneous panic. Mental status examination revealed that he was alert and angry that he had to keep switching doctors due to changes in psychiatrists in the clinic. He was less pressured, anxious and irritable than the last visit and the examiner noted that it appeared the first visit was very anxiety-provoking. There was some mild motor agitation and speech was not pressured. Mood was irritable and depressed and affect was mildly irritable. Thought process revealed no looseness of association and thought content revealed no psychosis. Passive suicidal ideation without intent or plan was noted, but there was no homicidal ideation. A March 2011 private psychologist report indicates that the Veteran reported struggling with disturbing recollections of images and thoughts, recurrent distressing dreams, and feeling as if he were re-living his traumatic experiences in fleeting flashback moments. The Veteran also reported that he experienced physical as well as emotional distress when exposed to things that remind him of those traumatic events. As a result, the Veteran had a long-term pattern of avoiding places or people that remind him of those experiences, or even discussing or thinking of those things. And though the Veteran cannot stop remembering many details of his traumatic experiences, he finds gaps in his memory of certain key details of those very same experiences. Subsequently, the Veteran had experienced a numbing of his tender or pleasant emotions, which leaves him feeling very detached from others, devoid of enthusiasm, and with little anticipation of a meaningful future. The Veteran also complained of chronic irritability, often erupting into outbursts of rage, and that he constantly felt tense and habitually scanning for potential dangers no matter where he is. The Veteran's mood was frequently one of hopelessness and sadness accompanied by apathy, loss of appetite, disturbed sleep, lethargy and diminished drive. His thoughts persistently gravitate to themes of worthlessness, guilt, self-loathing and, occasionally, suicide. The Veteran was thankful he worked outside because his neglect of grooming goes unnoticed. Further, he had difficulty making decisions, concentrating, and with short term memory (e.g. what has just been said, what he had just done, or where he had just come from). Aside from the symptoms themselves, much of the distress the Veteran experiences is from the toll of these long-term symptoms patterns have taken on important areas of his life. It was noted that he had attempted marriage four times and was currently divorced and "won't take a chance on number five." Regarding relationships, the Veteran reportedly kept to himself most of the time because he got irritated easily and could not handle the pressure that comes. He was "antsy in crowds" and had been told her often repeats himself. As a result of these factors, the Veteran had few friends and was distant from family members. The private psychologist reported that disability rating scale scores confirmed the Veteran had significant impairments in the following areas of functioning: understanding and memory (remembering locations and work-like procedures; understanding and remembering short and simple, as well as detailed, instructions); concentration and persistence (carrying out very short and simple, as well as detailed, instructions; maintaining attention and concentration for extended periods; staying on schedule, maintaining regular attendance, and being on time; working in coordination with or in proximity to others without being distracted by them; making simple work-related decisions; completing a normal work day without interruptions from psychological symptoms; maintaining a consistent pace without excessive rest periods); social interaction (interacting appropriate with the general public; asking simple questions or requesting assistance; accepting instructions and responding appropriate to criticism from supervisors; getting along with co-workers without distracting them or exhibiting behavioral extremes; maintaining socially appropriate behavior and adhering to basic standards of grooming); and adaptation (responding appropriately to changes in work setting; traveling in unfamiliar places or using public transportation; setting realistic goals or making plans independently of others). Axis I diagnoses of chronic PTSD and moderate major depression were made and a GAF score of 38 was assigned. The evidence of record supports the assignment of a rating of 50 percent for PTSD throughout the entire appeal period. As an initial matter, the Board notes that throughout the course of the appeal, the majority of the GAF scores assigned have fallen in the range of 55 or higher, a range that reflects moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV; see also VA and private treatment records; VA examination reports. Although the majority has reflected only moderate impairment, the remaining scores assigned fell in the range of 50 and below, a range that reflects serious symptoms or any serious impairment in social, occupational, or school functioning. See id. When taken in conjunction with the subjective symptoms reported by the Veteran, to include impaired relationships, withdrawal/isolation, nervousness, hypervigilance, easy distractibility, irritability, sleep impairment, insomnia, difficulty concentrating, impaired memory, intrusive thoughts, detachment, trouble controlling anger, depression, easy startle response, intolerance to anyone standing behind him, and distrust of people, the Board finds that these symptoms approximate the criteria for the assignment of a 50 percent rating throughout the entire appeal period. See VA and private treatment records; VA examination reports. The Board does not find that a rating in excess of 50 percent for PTSD is warranted, as the evidence of record does not more nearly approximate the criteria for the next higher, or 70 percent, rating. The Board acknowledges that the Veteran has more recently reported occasional suicidal ideation, and that he has also occasionally described impaired impulse control. Id. The Board also acknowledges that the Veteran reported at the time of the March 2011 private psychologist report that he was thankful he worked outside because his neglect of grooming goes unnoticed. There is no indication from the March 2011 report, however, that the Veteran exhibited neglect of personal appearance and hygiene. In addition, treatment records dated prior to March 2011 reflect that when noted, the Veteran always appeared neat and clean with good hygiene and clean, casual and appropriate attire. The Board also acknowledges that the Veteran has denied any relationship with his three children and that he has been divorced four times. Id. He is not, however, unable to establish and maintain effective relationships, as he has consistently reported involvement with the VFW (to include, more recently, the Purple Heart Chapter, which focuses more on fund raising efforts), has been able to attend group therapy intermittently throughout the entire appeal period, has reported going to church and out to restaurants and shops, has reported socializing with family, and has reported keeping in touch (to include visiting) with old service friends. Moreover, there is no evidence of such symptoms as obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation, or difficulty in adapting to stressful circumstances (including work or a worklike setting). The Board acknowledges the Veteran's reports of depression and the objective evidence of distractibility, impaired speech (noted to be rapid and mildly pressured), and impaired affect (noted to be animated and expansive when talking about his experiences in Vietnam). There is no indication, however, from either the subjective reports or objective evidence of record, that the Veteran has not been able to perform activities of daily living or routine activities. In addition, the August 2008 VA examiner specifically noted he was capable of performing his activities of daily living and did this routinely and independently. The Veteran has also consistently been deemed competent to manage his funds. Lastly, the Board emphasizes that the Veteran has been working as a concrete truck driver throughout the appeal period. For all these reasons, a rating in excess of 50 percent for PTSD is not warranted at any time during the appellate period. The Board finds that the Veteran does not have occupational and social impairment with deficiencies in most areas. Extraschedular consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b) (2013). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). The Court has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. First, the RO or 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 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." 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 C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The Veteran's PTSD symptoms cause impairment in occupational and social functioning, but such impairment is contemplated by the rating criteria and the Board finds that the rating criteria reasonably describe the Veteran's disability. Referral for consideration of an extraschedular rating is, therefore, not warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). ORDER A rating of 50 percent, and not higher, for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs