Citation Nr: 1332259 Decision Date: 10/18/13 Archive Date: 10/24/13 DOCKET NO. 09-17 988 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office and Insurance Center (ROIC) in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a rating in excess of 50 percent for post-traumatic stress disorder (PTSD) from April 16, 2008 through March 7, 2010. 2. Entitlement to a rating in excess of 70 percent for PTSD from March 8, 2010. REPRESENTATION Appellant represented by: Richard L. Frankel, Attorney at Law ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran served on active duty from December 1967 to December 1969. This matter comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from a July 2008 rating decision, by the VA Regional Office and Insurance Center (ROIC) in Philadelphia, Pennsylvania, which denied the claim for a rating in excess of 30 percent for PTSD. Subsequently, in a Decision Review Officer's (DRO) decision in August 2010, the RO increased the evaluation for PTSD from 30 percent to 50 percent, effective April 16, 2008, and from 50 percent to 70 percent, effective March 8, 2010. Because this award does not represent the highest possible rating available under the Rating Schedule for this disability and because the Veteran has not indicated that he is content with the new evaluation, his increased rating claim remains on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board notes that, in a statement dated in June 2010, the Veteran requested a personal hearing by videoconference at the local RO. The hearing was scheduled to be conducted at the VAROIC in Philadelphia in September 2013, however, the Veteran failed to report to the scheduled hearing. As the record does not contain any assertion of good cause for his failure to report, the Board deems the Veteran's request for a hearing to be withdrawn. 38 C.F.R. § 20.704. A review of the Virtual VA (VVA) paperless claims processing system reflects that VA/CAPRI records current through February 2013 are in the VVA file. The supplemental statement of the case (SSOC), issued in May 2013, reflects consideration of these records. In light of the award of an increased rating for PTSD, the matter of entitlement to a TDIU for any period prior to March 8, 2010 is referred to the RO for action deemed appropriate. See Rice v. Shinseki, 22 Vet. App. 447 (2009). FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's PTSD has been manifested by ongoing symptoms of depression and anxiety, difficulty sleeping due to recurring nightmares, flashbacks, intrusive thoughts, mood swings, outbursts of anger, irritability, hypervigilance, social isolation, passing homicidal ideations, difficulty with interpersonal relationships, resulting in occupational and social impairment with deficiencies in most areas, but without total occupational and social impairment. 2. From March 8, 2010, the Veteran's PTSD is not shown to be manifested by a disability picture that results in total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for a rating of 70 percent, but not more, for PTSD are met for the period from April 16, 2008 through March 7, 2010. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for an evaluation in excess of 70 percent for PTSD on and after March 8, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist. The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a statement of the case (SOC) or supplemental SOC (SSOC). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, VA satisfied its duty to notify by means of a letter dated in April 2008 from the RO to the Veteran which was issued prior to the RO decision in July 2008. Additional letters were issued in February 2010, March 2010, September 2010, November 2010, July 2011, and November 2011. Those letters informed the Veteran of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. The Board finds that the content of the above-noted letters provided to the Veteran complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify with respect to the issues decided herein. Regarding the duty to assist, the Veteran was provided an opportunity to submit additional evidence. It also appears that all obtainable evidence identified by the Veteran relative to the claims decided herein has been obtained and associated with the claims files, and that neither he nor his attorney has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of this appeal. It is therefore the Board's conclusion that the Veteran has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to VA notices. The Board is unaware of any outstanding evidence or information that has not already been requested with respect to the claim at issue. The Veteran has been afforded VA examinations on the issue decided herein. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations afforded the Veteran are adequate. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The examinations were conducted by medical professionals who reviewed the medical records, solicited history from the Veteran, and examined the Veteran. Findings necessary to apply the criteria for rating have been made. Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran in obtaining evidence pertinent to his claim. Therefore, no useful purpose would be served in remanding the issues decided herein for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Factual background. By a rating action in February 2007, the RO granted service connection for PTSD; a 30 percent disability rating was assigned, effective November 30, 2006. The Veteran's claim for an increased rating that led to the current appeal was received in April 2008. Submitted in support of the claim were VA outpatient treatment reports dated from September 2007 to February 2008. These records show that the Veteran received ongoing clinical attention for the PTSD symptoms. In January 2008, the Veteran reported problems sleeping; he also reported increased nightmares, hypervigilance and startled response. On mental status examination, speech was coherent; he denied any suicidal or homicidal ideations or plans. The Veteran was afforded a VA compensation examination in July 2008. At that time, the Veteran reported that he continued to experience recurrent memories and thoughts of Vietnam. It was noted that he had a long history of flashbacks that occur at irregular intervals. The Veteran stated that he felt that the flashbacks have been much worse over the past three years and associates this with the war reports from Iraq. The examiner noted that the Veteran had developed avoidance behaviors. It was noted that he continued to have a reduced interest in significant social activities and maintains a low level of socialization. The Veteran denied any significant changes in his socialization since his last evaluation in 2006. He continued to avoid crowds saying that he feels suspicious and sometimes pinned in when there is a large number of people. He was able to maintain his usual social activities that include having regular dinners out with his wife, staying close to his relatives and practicing his hobby of gardening. It was also noted that the Veteran had chronic insomnia with difficulty both in falling and staying asleep. He estimated that he sleeps three to four hours on the average night. He had a sustained high level of irritability that has been present since his last evaluation. He had occasional outbursts of anger. The Veteran also had a history of hypervigilance that is generally demonstrated at home when on a usual evening he will recheck the house on multiple occasions for security. He had an exaggerated startled reflex that has been present and unchanged since his return from Vietnam. The Veteran also reported that he continues to have long episodes in which he feels sad, had decreased mood, reduced energy and reduced motivation. The Veteran further reported that the casualty reports from Afghanistan and Iraq cause him to think about his own experience in Vietnam. On mental status examination, it was noted that the Veteran friendly and very cooperative. He was neatly dressed. His speech was clear and with normal rage and normal content. His psychomotor functions were full and normal. He had no difficulty carrying out activities of daily living. He was perfectly oriented to time, person and place, and his memory was excellent for remote and recent events. His intellectual functions and cognitive functions were normal. The examiner noted that the most dominant aspect of the Veteran's presentation were his low mood and sad affect. His level of anxiety was moderately high throughout the interview. He had no history of inappropriate behavior. He also denied having any suicidal or homicidal thoughts. He had a long history of chronic insomnia with interference with both the initial and middle phases of sleep. He described his appetite as usually good despite his mood. He had persistent feeling of low energy and low motivation. He complained of having a sustained high level of irritability. His insight and judgment were excellent. The pertinent diagnosis was PTSD, severe intensity; and major depressive disorder, secondary to PTSD, moderate intensity; he was assigned a GAF score of 46. The examiner noted that the Veteran had very prominent PTSD symptoms; his symptoms were intense with respect to re-experiencing the stressor and for symptoms of increased arousal. He had mild symptoms related to avoidance behaviors. The examiner noted that the Veteran's psychiatric symptoms fulfill the DSM-IV diagnostic criteria for PTSD, and he noted that the disorder is rated as having a severe intensity. The examiner also stated that the Veteran had a full complement of depressive symptoms that fulfill the DSM-IV criteria for major depressive disorder. The examiner observed that the depression was secondary to the PTSD; he noted that the depression is rated as having a recurrent course and a moderate intensity. The examiner concluded that, overall, the Veteran's clinical status has worsened to a moderate extent; he stated that this is mainly a consequence of an increase in intensity of several individual PTSD symptoms, a continuation of a moderate intensity depression and a strong reaction to the casualty reports from Afghanistan and Iraq. Of record is a statement from the Veteran's counseling therapist at the Vet Center, S. L. M., dated in October 2008. The therapist noted that since the Veteran started at the Vet Center, his symptoms have not abated or decreased but have increased in severity. She noted that the Veteran sleeps sporadically throughout the night and continued to have nightly nightmares. She also noted that the Veteran is frequently angry with numerous outbursts and incidents of road rage. He also reported increased marital stress, excessive worrying and feeling like its "doomsday" all the time. He reported thinking about Vietnam and reliving certain traumas over and over again in his head. The therapist noted that, since he stopped working four years ago, the Veteran reported an increase in his symptoms and that the world events are triggering intrusive thoughts. The pertinent diagnosis was PTSD, chronic with delayed onset; the therapist described the PTSD symptoms as severe. Received in October 2008 were VA progress notes dated from February 2007 to July 2008. These records show that the Veteran received ongoing clinical attention for his PTSD symptoms. The most prominent symptoms include irritability and hypervigilance; however, mental status evaluations reported coherent speech and the Veteran continually denied suicidal and homicidal ideations or plans. Received in May 2009 was a statement from the Veteran's spouse wherein she described his current symptoms and their effects of the marriage; she stated that their married life has become unbearable. The Veteran's wife related that he has become a very angry person and is verbally abusive. She also reported that the Veteran tosses and turns in his sleep, and the next day he is very irritable. She further noted that the Veteran acts like a caged animal in traffic; he curses and rants like a crazy person. She stated that her husband's condition is not getting any better; in fact, she noted that he's getting worse. The Veteran was afforded another VA examination in March 2010. At that time, the Veteran indicated that he has been receiving treatment on an outpatient basis for anger and anxiety; he stated that the medications helps him, but because he lost his license, he has not been able to go to therapy. It was noted that the Veteran received a DUI in 2009. It was also noted that the Veteran has been married to his third wife for 17 years; he stated that "it has been rough for my wife." It was further noted that the Veteran has four children, but he does not have a relationship with them. The Veteran reported "after the DUI, I was violent with the police officer; I got into a fight with someone in a party. He said something about Vietnam and I hit him." On mental status examination, it noted that the Veteran was casually dressed. He was restless. Speech was unremarkable. He was cooperative. Affect was constricted; his mood was anxious and dysphoric. The examiner noted that the Veteran was easily distracted. He was fully oriented. His thought process was circumstantiality. He expressed homicidal ideations and obsessions. No delusions or hallucinations were noted. Judgment and insight were intact. The Veteran reported interrupted sleep. No inappropriate behavior was noted. The examiner noted obsessions and germ related compulsions. He denied any panic attacks. It was reported that the Veteran had passive and transient homicidal thoughts. He denied any suicidal thoughts. The examiner noted that the Veteran is able to maintain good personal hygiene. The examiner noted that the Veteran had recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions. He also made efforts to avoid activities, places, or people that arouse recollections of the trauma, markedly diminished interest or participation in significant activities. The examiner reported that the Veteran has had moderate to severe symptoms of PTSD since his military trauma. It was noted that the Veteran was not currently working; he retired since 2003. The pertinent diagnosis was PTSD, chronic moderate to severe, and alcohol abuse secondary to PTSD: he was assigned a GAF score of 40. The examiner explained that the Veteran's GAF score is placed low due to his irritability level and his poor anger management; he noted that the Veteran does appear quite anxious and obsessive. The examiner stated that the Veteran's poor impulse control particularly in the past when he was drinking, his poor concentration, obsessions and hypervigilance are obstacles to his productivity and ability to work well with others. Received in April 2010 were VA progress notes dated from February 2007 to February 2010. These records show that the Veteran received ongoing clinical attention for the PTSD symptoms. Received in June 2010 were treatment reports from the Vet Center dated from November 2006 to May 2010. These records show that the Veteran attended group therapy sessions to manage his PTSD symptoms, including anger and anxiety. During a clinical visit in April 2010, the Veteran reported that he and his wife had an argument that morning over her son's irresponsible behavior; however, the Veteran was advised that his wife is not responsible for her son's behavior and that he should not take it out on her. He agreed and stated that he would apologize. On mental status examination, the Veteran's mood was described as irritable and affect constricted. It was noted that the Veteran's biggest challenge right now was his anger and how he frequently took it out on his wife; he stated that he did not know how to change that pattern of behavior. Received in August 2010 were VA progress notes dated from April 2010 to July 2010. These records show that the Veteran received ongoing clinical attention for the PTSD symptoms. On mental status examination, speech was coherent, and he denied any suicidal or homicidal ideations or plans. On the occasion of another VA examination in October 2010, the Veteran indicated that he was receiving outpatient treatment; he noted that they were helping some, but he still had a lot of rage and anger. It was noted that the Veteran has been married to his third wife for 17 years and he has four children. The Veteran reported that his wife was attending the significant other group and realized that the other women have the same problems. He noted that his kids will not see him. On examination, it was noted that the Veteran was casually dressed. He was described as tense. Speech was unremarkable. He was cooperative and attentive. Affect was constricted; mood was anxious and depressed. The examiner noted that the Veteran was easily distracted. He was fully oriented. The examiner noted some homicidal ideations and obsessions. No delusions or hallucinations were noted. It was reported that the Veteran has interrupted sleep and does not sleep very much. The examiner observed that the Veteran had obsessions and germ related compulsions. He had passive and transient homicidal thoughts. Impulse control was described as fair. Memory was described as normal. The examiner noted that the Veteran was able to maintain minimum personal hygiene. The pertinent diagnosis was PTSD, chronic, moderate to severe, and alcohol abuse secondary to PTSD; he was assigned a GAF score of 40. The examiner stated that the Veteran's anxiety, depression, poor concentration, anger, and his tendency to feel that "others take advantage of him" are obstacles to his ability to be productive and reliable in a work setting. Received in April 2011 were VA progress notes dated from January 2007 to July 2008. These records show that the Veteran received ongoing clinical attention for his PTSD symptoms. The most prominent symptoms include irritability and hypervigilance; however, mental status evaluations reported coherent speech and the Veteran continually denied suicidal and homicidal ideations or plans. Received in July 2012 was a notice of award from the Social Security Administration (SSA), dated in June 2012, informing the Veteran that he had been found to have become disabled as of November 20, 2006. Also received was a copy of the SSA decision, dated in June 2012, which found that the Veteran had not engaged in substantial gainful employment since November 20, 2006, due to severe impairments caused by PTSD, chronic, moderate to severe, and alcohol abuse, secondary to PTSD. Received in July 2012 were the medical records used by SSA in reaching its decision; these records include both VA as well as private treatment records, dated from November 2006 through February 2012. During a clinical visit in December 2009, the Veteran reported problems with anxiety and difficulty sleeping; on mental status examination, speech was coherent and he denied any suicidal or homicidal ideations or plans. When seen in June 2011, he complained of insomnia. He also complained of a next door neighbor who was harassing him repeatedly. It was noted that he was seeing a therapist at the Vet Center who reported significant anger management issues and road rage which the Veteran has not mentioned. On mental status examination, his mood and affect were euthymic. Thought processes were goal directed but he was preoccupied with being harassed by the neighbor; he denied any suicidal or homicidal ideations or plans. The Veteran was afforded another VA examination in September 2012. At that time, it was again noted that he has been married to his third wife and he described her as "a saint;" he stated that she loves him and he kind of love her, but he feels dead inside. The Veteran indicated that he has five children but he does not have a close relationship with them. The Veteran reported having several friends that he socializes with at the beach every summer; he stated that he does not socialize between October and June. It was noted that the Veteran retired as a Union Carpenter in 2004; he had a few part-time jobs as a carpenter in 2005, but he retired from the union with a partial pension. It was also noted that the Veteran has been receiving behavioral health treatment at the VA; he also receives both individual and group therapy. The examiner noted that the Veteran experienced depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or worklike setting. The pertinent diagnoses were PTSD, chronic, moderate to severe; and alcohol abuse, secondary to PTSD, in full remission. The Veteran was assigned a GAF score of 40. The examiner stated that, as far as employment is concerned, the Veteran's irritability, fatigue due to sleep disturbance, poor concentration, and hypervigilance are among the factors that reduce the Veteran's productivity and reliable attendance in a job setting. He noted that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. III. Legal Analysis. Disability evaluations are determined by the application of a schedule of ratings which is based upon average impairment of earning capacity. 38 U.S.C.A. § 1155. 38 C.F.R. § 4.1 (2013) requires that each disability be viewed in relation to its history, and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 (2013) requires that medical reports be interpreted in light of the entire recorded history, and that each disability must be considered from the point of view of the Veteran's working or seeking work. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating is to be assigned. The requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Moreover, VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. 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 concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. The severity of the Veteran's PTSD is determined by 38 C.F.R. § 4.130, Diagnostic Code 9411. Under this code, a 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as a 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires 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); or the inability to establish and maintain effective relationships. A 100 percent rating requires 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; or memory loss for the names of close relatives, own occupation, or own name. A GAF score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). This is more commonly referred to as DSM-IV. A GAF of 21 to 30 is defined as behavior considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriate, suicidal preoccupation) or an inability to function in almost all areas (e.g., stays in bed all day, no job, home or friends). A GAF of 31 to 40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or any 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 indicative of 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 indicative of 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. The Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. See 38 C.F.R. § 4.126 (2013). If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002 & Supp. 2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.3 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. After carefully considering the evidence of record in light of the rating criteria provided above, the Board finds the Veteran's service-connected PTSD warrants a 70 percent disability rating, but no higher, since his claim for an increased rating in April 2008. Significantly, the pertinent evidence of record during this period shows that the Veteran's service-connected PTSD was manifested by chronic depression, difficulty sleeping due to recurring nightmares about Vietnam, intrusive thoughts and flashbacks relating to his service in Vietnam. Other symptoms include chronic anxiety, hypervigilance, anger outbursts, irritability, and social isolation. The evidence reflects that the Veteran's PTSD symptoms were of such severity and persistence that they caused deficiencies in most areas, including his mood, family relations, and work. Significantly, throughout the appeal period, the Veteran described his mood as depressed and angry, and his affect has been variously described as anxious and sad. Indeed, on VA examination in July 2008, the examiner stated that the Veteran's clinical status had worsened to a moderate extent; he stated that this was mainly a consequence of an increase in intensity of several individual PTSD symptoms, a continuation of a moderate intensity depression and a strong reaction to the casualty reports from Afghanistan and Iraq. The examiner noted that the disorder was rated as having a severe intensity; in fact, he assigned a GAF score of 46. Moreover, the evidence of avoidance of social interaction is probative of difficulty adapting to stressful situations. The evidence of record shows that the Veteran experienced disrupted relationships with family, friends, and employers. In a statement from the Veteran's counseling therapist, dated in October 2008, it was noted that the Veteran was frequently angry with numerous outbursts and incidents of road rage. He also reported increased marital stress, excessive worrying and feeling like its "doomsday" all the time. He reported thinking about Vietnam and reliving certain traumas over and over again in his head. The therapist noted that, since he stopped working four years ago, the Veteran reported an increase in his symptoms; and he reported that the world events were triggering intrusive thoughts. The pertinent diagnosis was PTSD, chronic with delayed onset; the therapist described the PTSD symptoms as severe. Moreover, a decision from the SSA found the Veteran to have become disabled since November 20, 2006; it was determined that the Veteran had severe impairments caused by his PTSD and alcohol abuse secondary to PTSD. Overall, during the period in question, the Veteran demonstrated an inability to establish and maintain effective relationships of the type and degree that warrants a 70 percent rating for PTSD. In this case, the Veteran's GAF score was reported to be 46; a score of this severity reflects major impairment in several areas such as work, family relations, judgment, thinking or mood. His GAF most recently and prominently was shown to be 40, indicating findings showing employment problems, an inability to work with authority, and requiring an increase in his psychotropic medications. Consequently, he demonstrates occupational and social impairment with deficiencies in most areas; thus, the schedular criteria for a 70 percent evaluation have been approximated. The evidence does not, however, show that the veteran has symptoms that meet or approximate the criteria for a total schedular rating. Although the Veteran has persistent intrusive recollections, the mental status reports on psychological evaluation and examination did not find hallucinations or delusions, or give the impression that the intrusive recollections were hallucinatory in character or as disabling as persistent delusions or hallucinations. He does not manifest or nearly manifest the behavioral elements of 100 percent disability. There is no documented instance of grossly inappropriate behavior. While recent VA examination reports in March 2010, October 2010 and September 2012 noted some transient homicidal ideations, there is no documented instance of the veteran being an imminent danger to himself or others, let alone persistence of such danger. There is no report of any episodes of inability to perform activities of daily living. There is no clinical evidence of actual disorientation to time and place. There is no documentation of loss of memory of the names of close relatives, his occupation, or of his own name. In essence, total occupational and social impairment is not shown. The March 2010, November 2010, and March 2012 VA examination reports specifically found that the Veteran did not have total social and occupationally impairment due to his PTSD. Taking the evidence all together, the preponderance of it is against a rating higher than 70 percent for any time during the appeal period. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Indeed, the Board finds that the Veteran's PTSD symptoms, to specifically include his avoidance of social interaction, difficulty adapting to stressful social and work situations, and significant difficulty in establishing and maintaining effective work and family relationships, do not exceed the level of disability contemplated by the 70 percent rating. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.7 (2013). The veteran does not have such symptoms as contemplated by a 100 percent evaluation. See Mauerhan, supra. The record does reflect social and industrial impairment that is significant even if it is not total. The record further demonstrates that the PTSD symptoms, including poor impulse control, irritability and hypervigilance, clearly interfere with the Veteran's social and industrial capability. However, total impairment as contemplated by the schedule has not been demonstrated. Although the Veteran had difficulty establishing and maintaining relationships, he has remained married to his current wife for close to 20 years. The Veteran worked all his life according to the July 2008 VA examination report and took an early retirement in 2003 (though Social Security records suggest he worked until November 2006). The Veteran clearly engages in isolating and avoiding behaviors. Nevertheless, while there is significant impairment with his social activities, a 70 percent rating contemplates deficiencies in most areas, including family relations and the inability to establish and maintain effective relationships. The evidence of record does not total social and industrial impairment due to PTSD with depression. Given the above, and in light of the absence of findings consistent with symptoms commensurate with a 100 percent rating under Diagnostic Code 9411, to include evidence of total social impairment, the Board finds that the requirements for a schedular rating in excess of 70 percent have not been met. In sum, while a 70 percent evaluation is warranted for the period prior to March 8, 2010, the preponderance of the evidence is against a rating in excess of that amount prior to or since March 8, 2010. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Indeed, the Board finds that the Veteran's PTSD symptoms, to specifically include his avoidance of social interaction, difficulty adapting to stressful social and work situations, and significant difficulty in establishing and maintaining effective work and family relationships, more nearly approximate the level of disability contemplated by the 70 percent rating. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.7 (2013). Finally, the disability picture is not so exceptional or unusual as to warrant a referral for an evaluation on an extraschedular basis, either during the period from April 16, 2008 through March 7, 2010, or after March 8, 2010. Although the Veteran is currently unemployed, the assignment of the ratings described above appropriately addresses occupational impairment due to the Veteran's PTSD for the periods in question. Further, there is no competent evidence that the Veteran's service-connected PTSD has resulted in frequent hospitalizations. As noted above, his symptoms are those specifically contemplated by the schedular criteria. The Board is therefore not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b) (1) (2013). See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER A 70 percent rating for PTSD is granted for the period from April 16, 2008 through March 7, 2010, subject to the regulations governing the payment of monetary benefits. A rating in excess of 70 percent for PTSD since March 8, 2010 is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs