Citation Nr: 1332588 Decision Date: 10/21/13 Archive Date: 10/24/13 DOCKET NO. 12-01 697 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Devon Rembert-Carroll, Associate Counsel INTRODUCTION The Veteran had active service in the Army from June 1967 to May 1969. The matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, that in part, granted service connection for PTSD and assigned a 50 percent evaluation. The Veteran filed a notice of disagreement in October 2009 and was provided with a Statement of the Case (SOC) in November 2011. The Veteran perfected his appeal in January 2012 with a VA Form 9. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals VA treatment records dated August 2009 to July 2011. The other documents of record are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. FINDING OF FACT For the entire appeal period, the Veteran's symptoms of PTSD resulted in occupational and social impairment, with deficiencies in most areas due to depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, suicidal ideation, obsessional rituals which interfered with routine activities, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, difficulty in adapting to stressful circumstances, limited insight, irritability, isolation, exaggerated startle response, intrusive thoughts, guilt, anger, hypervigilance, avoidance, nightmares, flashbacks and GAF scores of 38, 39, 46, and 48. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, for the entire initial rating period, the criteria for an initial disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9434 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The Veteran's claim for a higher initial rating for PTSD arises from his disagreement with the initial evaluation assigned following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA also has a duty to assist the Veteran in the development of a claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). Here, the Veteran's statements and post-service VA treatment records have been associated with the claims folder. Additionally, the Veteran has not identified any other outstanding records that have not been requested or obtained. The Veteran was provided with VA examinations in June 2009 and November 2011. The Board finds that the VA examination reports are adequate because the examiners conducted clinical evaluations, reviewed the Veteran's medical history, and described the Veteran's PTSD in sufficient detail so that the Board's evaluation is an informed determination. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board thus finds that all necessary development has been accomplished and appellate review may proceed. See Bernard v. Brown, 4 Vet. App. 384 (1993). Legal Criteria Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. 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. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West 12 Vet. App. 119, 126 (1999). In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In the August 2009 rating decision, the Veteran's PTSD was evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). Under the General Rating Formula For Mental Disorders, to include PTSD, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assignable where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. 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. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2013). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 indicate some impairment in reality testing or communication such as, 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 such as, depressed man avoids friends, neglects family, and is unable to work. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2013). Background Post-service VA treatment records dated February 2005 to July 2011 shows that the Veteran was treated for PTSD. A March 2005 treatment record shows that the examiner noted the Veteran was had poor social and work functioning. On mental status examination the examiner noted that the Veteran was neat and well groomed. The Veteran was anxious, and had sad mood, congruent affect, and limited insight. The examiner noted that the Veteran was not suicidal or homicidal and assigned a GAF score of 39. An April 2005 treatment record shows that the Veteran reported being more aware of his irritability and that he consciously made an effort to prevent angry verbalizations, especially with customers. On mental status examination, the examiner noted that the Veteran had an anxious mood, constricted affect, and rationale thoughts. The examiner also noted that the Veteran was alert, attentive, and not suicidal or homicidal. The examiner assigned GAF score of 39. A February 2008 VA treatment record shows the Veteran reported being detached, withdrawn, and introverted. The Veteran also reported insomnia and waking several times per night. The Veteran also reported that he was easily startled and felt depressed. The Veteran denied nightmares, flashbacks, and suicidal ideation and history. A March 2008 VA treatment record shows that the Veteran reported blunted affect, intrusive thoughts, and detachment from others for decades. The Veteran reported that he felt numb and had no future other than to "work until I drop dead". The Veteran also reported feelings of guilt, a sense of failure, and intense anger. He reported that he was socially isolated, hypervigilant, and startled easily. The Veteran reported that he was often sad, irritable with his wife and customers, and had no pleasurable activities or interest. He also reported decreased concentration, a sense of purposelessness, and passive thoughts of death. The Veteran reported poor sleep, and denied a history of violence to self or others. He reported that he owns several firearms and has no close friends other than his sister and wife. The Veteran also reported that he owns a used car business. On mental status examination, the examiner noted that the Veteran was dressed in casual attire, was extremely guarded, and had a rigid posture with nervous fidgeting. The Veteran had limited reliability, little awareness of his moods and behavior, and impaired functioning. The examiner also noted that the Veteran's mood was very depressed, anxious, and guarded. The Veteran had a flat affect for most of interview, and anxious affect after hearing his diagnosis. The Veteran was attentive and his thought process was grossly intact with no obvious delusions, hallucinations, or referential thinking. The Veteran's speech had poor animation and low volume. The Veteran's insight was poor and his judgment and impulse control were intact. The Veteran had no suicidal or homicidal ideation, plan, or intent. The examiner diagnosed severe and chronic combat related PTSD and severe major depressive disorder. The examiner assigned a GAF score of 38. An April 2009 VA treatment record shows that the Veteran was very guarded and has a constricted affect. The Veteran's wife reported that "he won't interact with any one, he wants to be alone all the time, I can't get him to go out except for business". The Veteran reported years of intrusive thoughts, nightmares, night sweats at least twice a week, and very agitated sleep. The Veteran also reported that he has punched wife in his sleep. The Veteran reported that he avoids symbolic media related to combat and does not trust others including his wife. He reported that he has no friends, does not interact when people come to his home, and that he isolates himself in his garage when he is home. The Veteran reported a numbed feeling. He also reported that he stopped drinking 20 years prior but had become more isolated and withdrawn since. The Veteran also reported having no thoughts about his future and passive thoughts of dying but denied suicidal ideation. The Veteran reported that he is hypervigilant with multiple gates within his property. He reported that he gets furious if his wife forgets to lock the door. He also reported that he makes safety checks of his home and yard at night with his firearms. The Veteran reported that he startles easily, and has experienced a decline in concentration and short-term memory. The Veteran also reported conflict with his wife and customers. The Veteran reported a depressed mood and that he is easily irritated. The examiner noted that the Veteran was anhedonic, had fair drive only for work, and no leisure activities. The examiner also noted that the Veteran questioned his purpose in life and feels guilty. The Veteran reported that he can fall asleep easily but awakens alert shortly afterwards. He reported that he is up most of the night making safety checks and that he is tired during the day but cannot sleep. The Veteran reported that he had impaired decision making and less appetite. The Veteran reported suicidal ideation in the past but denied attempts. The Veteran also denied current suicidal ideation and homicidal ideation with no plant or intent. The Veteran also denied a history of violence to self or others. The Veteran reported that he has been married to current wife twice and that he has no children. On mental status examination, the examiner noted that the Veteran was neatly dressed and groomed and sat rigidly. The examiner noted that the Veteran had a "1000 yard stare" and was guarded. The examiner noted that the Veteran was hypervigilant, rather frozen, and had a fearful expression and posture. The Veteran had a constricted affect, depressed mood, and anxious mood. The Veteran was alert and fairly attentive. His memory was fair for recent and remote events and he frequently deferred to his wife. The Veteran had little animation or spontaneity in his speech, with slight stuttering. His speech was reticent, average volume, and minimal elaboration. The Veteran was slow to process information and looked to his wife for guidance or stared out the window. The Veteran had no delusions, hallucinations, or referential thinking. The examiner noted that the Veteran's, insight was poor and his judgment and impulse control were fair. The Veteran denied suicidal and homicidal ideation and the examiner assigned a GAF score of 38. A May 2009 VA treatment record shows that the Veteran reported depression, a high anxiety level, and constant intrusive thoughts about combat. The Veteran also reported avoidance behaviors and hyperarousal symptoms that gravely impaired his social and occupational functioning. The Veteran denied suicidal and homicidal ideation plan or intent. On mental status examination, the Veteran was alert, fully oriented and hypervigilant. The examiner noted that the Veteran was neatly dressed and groomed, tense, and slightly less guarded. The examiner also noted that the Veteran was anxious and had a depressed mood and affect. The Veteran's speech was a bit more spontaneous, coherent, relevant, normal rate and volume, and fairly monotone. The Veteran's thought process was fairly rationale and goal oriented. The Veteran's thought content was baseline suspicious. The Veteran had no delusions, hallucinations, or referential thinking. The Veteran's insight was limited and his judgment and impulse control were fair. The examiner noted that the Veteran was not suicidal or homicidal and assigned a GAF score of 38. A June 2009 VA treatment record shows that the Veteran's emotional response often included intense fear, helplessness, and horror. The Veteran reported intrusive memories, distressing dreams, flashbacks, and intense psychological and physiological reactivity when exposed to symbolic material related to his trauma. The Veteran also reported avoidance behavior, diminished interest in significant activities, and feelings of detachment and estrangement from others. The Veteran reported a restricted range of affect, a sense of a foreshortened future, and sleep difficulties. He also reported irritability, angry outburst, concentration difficulties, hypervigilance, and exaggerated startle response. On mental status examination, the examiner noted that the Veteran made good eye contact, appeared well groomed, was cooperative, alert, and oriented to person, time, place, and situation. The Veteran's speech was a normal rate and volume. He also had logical and organized thought form with non-bizarre thought content. The Veteran's mood was anxious and depressed, with constricted affect. The Veteran denied suicidal and homicidal ideation. The examiner noted that the Veteran's memory was grossly intact and his insight, judgment and impulse control were good. Another June 2009 VA treatment record shows that the Veteran continued to have intrusive thoughts, avoidance behaviors, and hyperarousal symptoms. The Veteran also reported that he felt depressed and guilty. He reported that he makes safety checks of his home and yard nightly and that he is very socially isolated. The Veteran denied suicidal and homicidal ideations. On mental status examination the examiner noted that the Veteran was alert and fully oriented. The examiner also noted that the Veteran was fidgety. The Veteran also had a depressed mood and guarded mood and affect. The Veteran's speech was reticent, coherent, relevant, cautious in manner, a low volume, and had little spontaneity or animation. The Veteran's thought a process was rational. The examiner noted that the Veteran was preoccupied with potential dangers in his environment. The examiner noted that the Veteran had no delusions, hallucinations, or referential thinking. The examiner also noted that the Veteran's insight was limited and his judgment and impulse control were fair. The examiner noted that the Veteran had no suicidal or homicidal ideations and assigned a GAF score of 38. The Veteran was afforded a VA examination in June 2009. The Veteran reported that he has been married to the same woman twice, ten years the first time and eight years the second time. He reported that they argue a lot and that she struggles with his control, being right all the time, and irritability. He reported that she wants to socialize and he does not want to go. The Veteran reported that he felt detached and denied social relationships. He reported that he stays at home, has no real hobbies, and that he works all day into the evenings and goes home with some work on the weekends. The Veteran also denied a history of suicide attempts or violence and assaultiveness. He reported that he was isolated, avoidant, and withdrawn. On mental status examination the examiner noted that the Veteran was appropriately and casually dressed. The Veteran was fatigued and tense. The Veteran's speech was hesitant and coherent. The examiner noted that the Veteran was cooperative, indifferent, and guarded. The Veteran's mood was dyphoric and bland and his attention was intact. The Veteran was oriented to person, place and time. The examiner also noted that the Veteran appeared distracted and scattered. The Veteran had no ruminations or delusions and understood the outcome of behavior. The Veteran's insight was poor. The Veteran reported sleeping six hours with a break at 2am to check outside. The Veteran had no hallucinations or inappropriate behavior. The Veteran obsessively checked locks in the day and at night. The Veteran denied panic attacks and suicidal or homicidal ideations. The Veteran's impulse control was good and he had the ability to maintain minimum personal hygiene. The examiner noted the Veteran had problems with sports, exercising, and other recreational activities. The Veteran's remote memory and recent memory were mildly impaired and his immediate memory was normal. The examiner noted that the Veteran seemed to have problems recalling data, details, names, numbers, and a problem with misplacing items and occasionally forgetting what he was supposed to do in the middle of cleaning cars. The examiner noted that the Veteran's symptoms were frequent, chronic, and moderate to severe. The Veteran reported that he avoids people and other veterans. The Veteran reported a lack of enjoyment in life and a short fuse with customers. The Veteran also reported that he has been self employed for 20 years. The examiner noted that the Veteran's problems related to occupational functioning included memory loss and poor social interaction. The examiner diagnosed PTSD and assigned a GAF score of 46. An October 2009 VA treatment record shows that the Veteran reported that he sleeps less than four hours per night and makes nightly armed "patrols" of his property. The Veteran reported that a neighbor complained to the police about this but he does not go outside his own fenced property. The Veteran also reported that he was having more memory and concentration problems. The Veteran denied suicidal or homicidal ideation, plan, or intent. The Veteran reported that he continued to have severe intrusive thoughts of combat though he minimized actual distress. He reported that he relies heavily on his wife for daily functioning at home and their business. The Veteran also reported strong avoidant behaviors, detachment from others, and hyperarousal symptoms. On mental status examination, the examiner noted that the Veteran was alert, fully oriented, and neatly dressed and groomed. The Veteran was hypervigilant, watched windows, and kept the door ajar. The examiner noted that the Veteran was slow and very cautious. The Veteran's mood and affect were rather blunted. The Veteran's speech was coherent, relevant, and a slow rate and volume. The Veteran's thought process was fairly rational. His thought content included a high degree of suspiciousness consistent with a diagnosis of PTSD. The Veteran had no hallucinations. The Veteran's insight and judgment were limited and his impulse control was fair. The examiner assigned a GAF score of 38. A June 2010 VA treatment record shows that the Veteran reported that he avoids customer interactions and is frequently short-tempered. The Veteran reported that he "shuts down" when annoyed. The Veteran also reported that he is socially detached and isolated and feels guilty because of this. He also reported that he makes rounds of his yard nightly armed with a knife. The Veteran reported that lately he had been more depressed, irritable, and sad. He also stated that he is frustrated with the chronicity of his PTSD symptoms and feels like he is on a treadmill "and not going anywhere". On mental status examination the examiner noted that the Veteran was alert, fully oriented, and neatly dressed and groomed. The examiner noted that the Veteran was hypervigilant and had the usual nervous manner and "1000 yard stare". The Veteran was also tense and anxious. His mood was sad and anxious and he had a constricted affect. The Veteran's speech was tentative, coherent, relevant, low volume, and anxious style. The Veteran had a simple goal oriented thought process. The Veteran's thought content included a theme of sadness and loss. The Veteran had no delusions, hallucinations, or referential thinking. The Veteran's insight was limited and his judgment and impulse control were fair. The Veteran was not homicidal or suicidal and denied ideation, plan, or intent. The examiner assigned a GAF score of 38. A July 2010 VA treatment record shows that the Veteran reported that he works at his business daily to stay busy but avoids social interactions. He reported that he has some night sweats and nightmares and that he recently bumped his wife in the head during agitated sleep. The Veteran reported that he wakes frequently at night and sits in the garage and watches the house. On mental status examination the examiner noted that the Veteran was alert, fully oriented, and neatly dressed and groomed. The Veteran was hypervigilant, left the office door ajar, and had limited eye contact due to scanning. The Veteran's motor movements were within normal limits and he had an anxious mood and affect. His speech was, coherent, relevant, less reticent, and normal rate and volume. The Veteran had an organized, goal directed thought process. The Veteran's memory was intact and he had no delusions, hallucinations, or referential thinking. The Veteran's insight was limited, and his judgment and impulse control were fair. The Veteran also denied suicidal or homicidal ideation, plan, or intent. The examiner assigned a GAF score of 39. A September 2010 VA treatment record shows that on mental status examination the Veteran was alert, fully oriented, and neatly dressed and groomed. He was hypervigilant and had the usual "1000 yard stare". The Veteran's motor movements were tense and he had sad, blunted mood and affect. The Veteran's speech was reticent, coherent, relevant, normal rate and volume, and flat toned. The Veteran's thought process was goal directed. His thought content included many worries regarding safety. The Veteran had no delusions, hallucinations, or referential thinking. The Veteran's insight and judgment were fair and his impulse control was intact. The Veteran was not homicidal or suicidal and denied ideation, plan, or intent. The examiner assigned a GAF score of 39. A November 2010 VA treatment record shows that the Veteran reported more numbing and avoidance behaviors. He also reported that he overreacts if a door is found unlocked in his home. The Veteran reported that he has less ambition and interest. He also reported that he plans on working for diversional activity. The Veteran also reported that he was isolated as always. On mental status examination the examiner noted that the Veteran was alert, fully oriented, and neatly dressed and groomed. The examiner noted that the Veteran was hypervigilant, constantly scanned widows and left the office door open purposefully. The Veteran's motor movements were tense and his mood was anxious, sad, and reflective. The Veteran's affect was blunted. The Veteran's speech was spontaneous, coherent, relevant, and normal volume and rate. The Veteran's thought process was organized and goal directed. The Veteran's memory was intact. The Veteran's thought content included preoccupation with trauma memories. The Veteran had no delusions, hallucinations, or referential thinking. The Veteran's insight was limited, and his judgment and impulse control fair. The Veteran denied suicidal and homicidal ideation, plan, or intent. The examiner assigned a GAF score of 39. A May 2011 VA treatment record shows that the Veteran reported working part-time at his own business and that he was always nervous. The Veteran also reported restless sleep and that he is hypervigilant. He reported that he isolates himself from family and others. He also reported night sweats and nightmares occasionally. The Veteran also reported that he is more forgetful. On mental status examination the examiner noted that the Veteran was alert, fully oriented, and neatly dressed and groomed. The examiner noted that the Veteran had the baseline "1000 yard stare" and was hypervigilant. The Veteran's movements were tense and guarded. The Veteran had a depressed and anxious mood and a constricted affect. The Veteran's speech was reticent, coherent, relevant, low volume, and normal rate. The Veteran's thought process was goal oriented and his memory was grossly intact. The Veteran's thought content included a theme of fear and distress. The Veteran had no delusions, hallucinations, or referential thinking. The Veteran's insight was slightly improved, his judgment fair to average, and his impulse control average. The Veteran denied suicidal and homicidal ideation, plan, or intent. The examiner assigned a GAF score of 39. A July 2011 VA treatment record shows that the Veteran reported hypervigilance and difficulties with nightmares. On mental status examination the examiner noted that the Veteran was casually dressed in shorts and a polo shirt. The Veteran was oriented to person, time, and place. His mood was anxious, his affect congruent, and his speech was normal. The Veteran had no perceptual disturbances or thought disorders and his insight and judgment were fair. The Veteran was afforded another VA examination in November 2011. The Veteran reported that he had been married for nearly 20 years with no children. He reported that there was marital conflict with his wife and "she says everything has to by my way, she gets upset with me a lot, I have my own way and everything has to be locked up secure". The Veteran also reported that his wife helps him run the business because "she deals with the people, she's better at that than me". The Veteran also reported that outside of work "I like to be by myself I don't go anywhere, or do anything outside of work, I don't like to be around people, I kind of control the situation when I'm by myself". He also reported that "my neighbor called the police on me; she said I took her flag, I fenced my house off, nobody comes in or out". On mental status examination, the examiner noted that the Veteran had a depressed mood, anxiety, suspiciousness, and near continuous panic or depression affecting the ability to function independently appropriately and effectively. The Veteran also had chronic sleep impairment, mild memory loss such as forgetting names directions or recent events, and difficulty in understanding complex commands. He also had impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner noted the Veteran also had difficulty in adapting to stressful circumstances including work or worklife setting and an inability to maintain effective relationships. The Veteran also had suicidal ideations, obsessional rituals which interfere with routine activities, and impaired impulse control such as unprovoked irritability with periods of violence. The examiner noted that the Veteran's other symptoms included difficulty concentrating with inefficiency at work, repeating tasks and actions, depressed mood, self-recrimination, and crying spells. The Veteran denied current suicidal ideation, impulses, plan, or intent. The Veteran also reported no history of homicidal ideation "since I got out of Vietnam". The examiner diagnosed PTSD and depressive disorder related to PTSD and assigned a GAF score of 48. Analysis Having considered all the evidence of record and the applicable law, the Board finds that for all periods under consideration an initial 70 percent rating for PTSD is warranted. As outlined above, the Veteran's PTSD has manifested as occupational and social impairment, with deficiencies in most areas due to depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, impaired impulse control, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, suicidal ideation, obsessional rituals which interfered with routine activities, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, difficulty in adapting to stressful circumstances, limited insight, irritability, isolation, exaggerated startle response, intrusive thoughts, guilt, anger, hypervigilance, avoidance, nightmares, and flashbacks. The Board notes that the Veteran did not exhibit all the symptoms for a 70 percent rating. Nonetheless, the Board finds that the functional impairment due to the above symptomatology during the entire appeal period more nearly approximates the criteria for a 70 percent rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (symptoms recited in the rating schedule for mental disorders are to serve as examples of the type and degree of the symptoms and not an exhaustive list). Based on the evidence of record, the Boards finds that the Veteran's PTSD symptoms do not warrant an initial rating of 100 percent. Total occupational and social impairment has not been shown in that the Veteran maintains, although with conflict, a long term relationship with his wife and continues to be self-employed. Similarly, his symptoms have not been manifested by 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 daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. The evidence of record shows that the Veteran's thought process was continuously found to be rational and goal directed. The Veteran's speech was also found to be coherent and relevant and the Veteran repeatedly denied delusions or hallucinations. VA treatment records and the June 2009 and November 2011 VA examinations show that the Veteran's behavior was not inappropriate. The Veteran repeatedly denied homicidal ideation, and although admitting to past suicidal ideation, the Veteran repeatedly denied current thoughts or plans. VA treatment records, as well as the June 2009 VA examination show that the Veteran was found to be oriented to person, place, and time. Furthermore, while the Veteran showed some mild memory loss, the evidence of record does not show that the Veteran's memory loss included names of close relatives, own occupation, or own name. The Board realizes that the symptoms noted in the rating criteria are not intended to be an exhaustive list, but are examples of the types and severity of symptoms that indicate a certain level of disability. Thus, the Board believes that based on the overall record evidence, including the Veteran's lay statements, the effects of the Veteran's PTSD symptoms have not been described to be of a type, frequency and severity that are in accord with the level of impairment contemplated by the criteria for a 100 percent schedular rating. The Board acknowledges that the Veteran has been assigned GAF scores of 38, 39, 46, and 48. GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 indicate some impairment in reality testing or communication such as, 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 such as, depressed man avoids friends, neglects family, and is unable to work. While the GAF scores are not determinative by themselves, the Board finds that these GAF scores, combined with the evidence of record, illustrates that the type, frequency and severity of the Veteran's PTSD symptoms reflects a level of impairment that most closely approximate a 70 percent disability, but not higher, throughout the entire period on appeal. The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 3.321(b)(1). However, there is no objective evidence that any manifestations related to the Veteran's PTSD are unusual or exceptional. For the reasons discussed above, the Board finds that the schedular rating criteria adequately contemplate the impairment caused by the Veteran's PTSD. In view of this, referral of this case for extraschedular consideration is not in order. See Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the Court has held that entitlement to a TDIU is an element of all appeals for a higher rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised when a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. The Board notes that the Veteran is self-employed and has reported that he works to stay busy. As there is no evidence that the Veteran's service-connected PTSD precludes employment, the question of entitlement to a TDIU is not raised. ORDER Subject to the laws and regulations governing monetary awards, an initial rating of 70 percent, but no higher, for PTSD is granted, subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs