Citation Nr: 1334264 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 10-10 059 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an increased disability rating for posttraumatic stress disorder (PTSD) rated as 30 percent disabling prior to February 5, 2009. 2. Entitlement to an increased disability rating for PTSD rated as 50 percent disabling from February 5, 2009 through February 28, 2010. 3. Entitlement to an increased disability rating for PTSD rated as 50 percent disabling from May 1, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from November 1968 through August 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. A timely Notice of Disagreement (NOD) was received in April 2009. In a February 2010 Statement of the Case (SOC), the RO granted a higher 50 percent disability rating for PTSD, effective February 5, 2009. The Veteran perfected his appeal in February 2010, via VA Form 9 substantive appeal in which he indicated his desire to continue his appeal. In view of the foregoing history, the Veteran is presumed to be seeking the maximum available benefit for his PTSD. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). During the course of subsequent development, the RO issued an August 2010 rating decision which granted a 100 percent disability rating, due to hospitalization for treatment of PTSD, effective from March 1, 2010 through April 30, 2010. Also pursuant to this rating decision, the disability rating assigned for the Veteran's PTSD was to be returned to 50 percent, effective from May 1, 2010. The Board notes that the Veteran also initiated an appeal as to the issue of entitlement to service connection for irritable bowel syndrome, claimed as secondary to diabetic autonomic neuropathy attributable to his service-connected diabetes mellitus, type II. In that regard, and in response to an August 2010 rating decision denying service connection for that disability, the Veteran filed a timely NOD in September 2010. Although an SOC addressing that issue was provided in February 2011, the Veteran did not subsequently perfect his appeal as to that issue by filing a substantive appeal or otherwise indicating his desire to pursue his appeal as to that issue. Accordingly, that issue does not remain on appeal before the Board. FINDINGS OF FACT 1. Prior to February 5, 2009, the Veteran's PTSD was manifested by symptoms which included anxiety marked by increased startle responses, nervousness, and edginess; depression marked by frequent crying spells; and chronic sleep impairment marked by nightmares and awakening at night. 2. For the period from February 5, 2009 through February 28, 2010, the Veteran's PTSD was manifested by symptoms which included anxiety; sleep problems marked by recurring nightmares; anger; suicidal ideation; lethargic psychomotor activity; slowed speech rate; anhedonia; flattened affect; a degree of social isolation; and some difficulty in adapting to stressful circumstances, as indicated by the Veteran's admission that he did not believe himself capable of working in a school setting around students and teachers due to his anger and irritability. 3. Since March 1, 2010, the Veteran's PTSD has been manifested by symptoms which include sleep disturbance marked by nightmares; flashbacks triggered by loud noises and certain smells; recurrent intrusive recollections avoidance of thoughts and feeling associated with combat trauma; avoidance of activities and situations that might arouse recollections of trauma; markedly diminished interest in activities and feelings of estrangement or detachment from others; a sense of a foreshortened future; hypervigilence; and exaggerated startle responses. Notwithstanding the foregoing symptoms, the Veteran has maintained a high level of social and occupational function and close relationships with his family. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating for PTSD rated as 30 percent disabling, prior to February 5, 2009, have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for an increased disability rating for PTSD rated as 50 percent disabling, from February 5, 2009 through February 28, 2010, have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for an increased disability rating for PTSD rated as 50 percent disabling, from March 1, 2010, have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Such notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). A February 2009 pre-rating letter provided the Veteran with notice of the information and evidence needed to substantiate his claim for an increased disability rating for his service-connected PTSD. Consistent with Dingess, this letter included notice of the process in which VA assigns disability evaluations and effective dates. Subsequently, the Veteran's claim for a higher disability rating was adjudicated in the RO's April 2009 rating decision. Thus, because the VCAA notice in this case was legally sufficient, VA's duty to notify in this case has been satisfied. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. His service treatment records, claims submissions, lay statements, identified and relevant private treatment records, and VA treatment records have been obtained and associated with the record. VA examinations for the Veteran's PTSD were conducted in March 2009, October 2009, and June 2010. Moreover, VA has not received any additional evidence since the most recent June 2010 examination which indicates that the Veteran's condition has changed such as to warrant the scheduling of a new VA examination to reassess the symptoms and severity of his PTSD. Hence, these examinations, along with the other evidence of record, are fully adequate for the purposes of determining the extent of the Veteran's disability in light of the applicable diagnostic criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. II. Increased Disability Ratings for PTSD Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. §§ 3.102, 4.3. Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). For all periods relevant to this appeal, the Veteran's PTSD has been rated in accordance with 38 C.F.R. § 4.130, DC 9411, which provides the rating criteria specifically for PTSD. DC 9411 requires that PTSD be rated under the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, a 30 percent disability rating is appropriate where the evidence shows that PTSD is productive of occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (i.e., forgetting names, directions, and recent events). A 50 percent disability rating encompasses PTSD that is manifested by 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 disability rating is appropriate for PTSD that is manifested by 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 that is 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 disability evaluation is assigned where PTSD is productive of 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 himself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; or memory loss for the names of close relatives, own occupation, or own name. A. Prior to February 5, 2009 Service connection for PTSD was initially granted for the Veteran in an August 1984 rating decision, effective December 20, 1983, with a noncompensable initial disability rating. Subsequently, an April 2005 rating decision granted a 30 percent disability rating, effective June 16, 2005. That disability rating remained undisturbed through receipt of the Veteran's pending claim for increase on February 5, 2009. Generally, the effective date for an increased disability rating is the date of receipt of the claim or the date on which entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). If, however, the claim is filed within one year of the date that the evidence shows that an increase in disability has occurred, the effective date is the earliest date as of which an increase is factually ascertainable (not necessarily the date of receipt of the evidence). 38 C.F.R. §§ 3.157(b)(1), 3.400(o)(2); see also Harper v. Brown, 10 Vet. App. 125, 126-27 (1997). Hence, the relevant focus for adjudicating a claim for an increased disability rating is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart, 21 Vet. App. 505. Mindful of the same, the Board has endeavored to consider whether the Veteran was entitled to a disability rating higher than 30 percent for the period from February 5, 2008 through February 5, 2009. The evidence relevant to the appeal period outlined above includes VA treatment records which pertain to regular psychiatric treatment received by the Veteran. During March 2008 treatment, the Veteran reported ongoing nightmares with associated terrors and anxiety; anger and frustration, particularly in regard to the war in Iraq; and hypervigilence manifested by behaviors such as positioning himself with his back to the wall. During the examination, the Veteran exhibited a mild startle reaction to hearing scratching on the door. Nonetheless, the remainder of the mental status examination was apparently within normal limits. In that regard, the Veteran was noted as being alert and oriented, well-groomed, cooperative, and using good eye contact. Demonstrated speech was clear and organized and had regular rate and rhythm. Demonstrated mood was euthymic with anxious affect. There was no indication of hallucinations, suicidal or homicidal ideation, or delusions. The Veteran's judgment and insight were good. A Global Assessment of Functioning (GAF) scale score of 58 assigned. During follow-up evaluations later that month, the Veteran also reported that he was having relationship difficulties with his spouse, and with his wife in attendance at the treatment, admitted to having an affair. The treating VA psychologist opined that PTSD is not the primary etiological factor in the Veteran's relationship problems, and determined instead that his relationship problems more likely related to a personality disorder with narcissistic and anti-social features. In another follow-up evaluation later that month, the Veteran acknowledged having a relationship with a married co-employee whom he insisted was in an abusive marriage and was in need of emotional support. He also reported that he was having homicidal fantasies. During evaluation and treatment in April 2008, the Veteran reported that he was spending time with his grandchildren. Although he stated that he was separated from his spouse, he reported that he was maintaining a relationship with a girlfriend, whom he as seeing once per week. A mental status examination performed that month revealed that the Veteran was mildly depressed, moderately anxious and tense, and appeared to avoid eye contact. Nonetheless, the Veteran remained alert and oriented. His demonstrated speech remained unremarkable. His cognition appeared to be intact and his demonstrated judgment and insight were good. A GAF score of 60 was assigned. During treatment in June 2008, the Veteran reported that he was still working and had recently secured a job as a school principle and was teaching on three nights per week during the summer. Concerning his symptoms, he reported that he was having ongoing sleep problems. A mental status examination performed during that month revealed that the Veteran remained tense, anxious, and nervous, but was otherwise stable. In that regard, his mood was observed as being euthymic and there was no evidence of hallucinations, delusions, suicidal ideation, or homicidal ideation. His demonstrated judgment and insight remained good. A GAF score of 58 was assigned. Treatment and evaluation performed in July 2008 did not reveal any significant changes in the Veteran's mental status. The Board notes, however, that the Veteran began reporting that he was having crying spells. In August 2008, the Veteran indicated that he was still working, but stated that he did not like his job and was actively searching for another. Socially, he stated that the divorce process from his spouse was on hold, and he reported problems in his current relationship with his girlfriend because he did not feel that he was receiving the same emotional support from her that he did in the past. Concerning his symptoms, he reported that was sleeping better due to medication, but that he was still having occasional nightmares. He stated that he went biking with a neighbor but that he was spending most nights having crying spells. A GAF score of 60 assigned. During evaluation in September 2008, the Veteran continued to report that he was sleeping adequately; however, stated that rain reminded him of his service in Vietnam and that this gave him a sense that he was waiting in ambush. He reported work stress, however, stated that he was being assigned a superintendent and a couple of other administrators, presumably to work beneath him. Socially, he reported being happy about his divorce and that he was receiving support from his girlfriend during regular telephone conversations with her. A GAF score of 55 was assessed. In November 2008, the Veteran reported that his divorce was finalized and that he was maintaining regular telephone contact with his girlfriend. He continued to report recurrent dreams about Vietnam and that he was having crying spells that occurred three or four times per month. Nonetheless, he stated that other than his crying spells, he felt "pretty good" over the rest of the month. During a follow-up treatment visit later that month, he indicated anhedonia, intermittent insomnia that was improved with medication, and daytime edginess that was also improved with medication. A mental status examination revealed that the Veteran remained alert and oriented to person, place, and time. He remained neatly and casually groomed and demonstrated calm body language. Demonstrated mood continued to be mildly euthymic, but was melancholic at times with congruent affect. Demonstrated speech remained clear and coherent with linear and goal-directed content and speech rate and tone were also within normal limits. There was no evidence of word searching, derailment, or blocking and no evidence of perceptual distortions. The Veteran expressly denied having any suicidal ideation, homicidal ideation, hallucinations, panic attacks, paranoia, isolative behavior, feelings of helplessness or hopelessness, or mood swings. Based upon these findings and the Veteran's complaints, the treating VA psychologist provided Axis I diagnoses of PTSD with severe chronic symptoms that were exacerbated by increased life stress and adjustment disorder with depressed mood and grief. The following month, in December 2008, the Veteran reported being depressed around the holidays. He stated that his spouse had moved her things out of the house, but that he was planning to see his children during the holidays. In January 2009, the Veteran reported that he was feeling depression secondary to his divorce. Occupationally, he stated that he was still working. He also reported symptoms of feeling worried; difficulty concentrating; poor memory; and sleep disturbances marked by nightmares occurring three or four times per week, waking startled, and feeling frightened. During a mental status examination, the Veteran demonstrated new symptoms of lethargy and mild to moderate psychomotor retardation. He continued to show moderate to severe anhedonia and poor motivation. Notwithstanding these symptoms, the Veteran remained neatly and casually groomed and continued being alert and oriented to person, place, and time. His demonstrated mood remained unchanged and was still mildly euthymic but melancholic at times. His demonstrated speech continued to be within normal limits. Apparently, objective testing of the Veteran's memory and concentration were not performed, as the results of such testing were not reported. Once again, the Veteran denied having any suicidal or homicidal ideation; hallucinations; panic attacks; paranoia; isolative behavior; appetite changes; feelings of helplessness or hopelessness; or mood swings. The VA psychologist continued to diagnose PTSD with severe chronic symptoms exacerbated by lifestyle and new health problems, and adjustment disorder with depressed mood and grief. The evidence relevant to the appeal period prior to February 5, 2009 shows that the Veteran's PTSD was manifested consistently by symptomatology that is consistent with a 30 percent disability rating, and no more, under the General Formula. In that regard, the Veteran consistently demonstrated anxiety marked by increased startle responses, nervousness, and edginess; depression marked by frequent crying spells; and chronic sleep impairment marked by nightmares and awakening at night. In regard to these symptoms, the Veteran reported that they were being managed by psychiatric medications. As noted above, the Veteran reported diminished concentration and memory problems during his January 2009 evaluation and treatment. However, there is no objective evidence of such symptoms during the appeal period at issue. Moreover, even taking into consideration the Veteran's complaints of decreased concentration and diminished memory, there is simply no evidence of any other symptoms that are consistent with a disability rating higher than 30 percent under the General Formula. Socially, the evidence shows that the Veteran was experiencing problems in his marriage; nonetheless, the evidence also shows that the Veteran's marital problems were not attributable to his PTSD. In that regard, the treating VA psychologist opined in March 2008 that they were due to a personality disorder with narcissistic and anti-social features. Despite his marital problems, the Veteran was apparently able to maintain relationships with the rest of his family, including his grandchildren and children, as indicated during his April 2008 and December 2008 VA treatments. During his August 2008 VA treatment, he stated that he went biking with his neighbor. Moreover, the Board notes that the Veteran was able to maintain an extramarital affair and an apparent longterm relationship with his girlfriend. Indeed, during VA treatment, he reported that he maintained regular contact with his girlfriend and that such contact provided him with emotional support. Occupationally, despite his complaints of being dissatisfied with his work, the evidence shows that the Veteran was able to maintain employment as a school principal and was even able to maintain work during the summer as a part-time teacher. Indeed, in September 2008, he indicated that a superintendant and school administrators were being assigned to him. Overall, the foregoing evidence is not consistent with difficulty in establishing and maintaining effective work and social relationships. In terms of his overall functioning, there is also simply no evidence that the Veteran's PTSD impacted his activities of daily living. In that regard, the Veteran was able to maintain hygiene and appearance and there was no evidence of any inability to perform his other activities of daily living. The Board also notes that, generally, the Veteran's GAF scores prior to February 5, 2009 range consistently from 55 to 60. In assessing the degree of psychiatric disability, GAF scores are for application and reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). According to the DSM-IV, a GAF score falling in the range of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). The Board admonishes that GAF scores are not conclusively dispositive as to a veteran's level of psychiatric impairment. Rather, GAF scores are merely parts of a whole body of evidence that must be and has been considered in arriving at a decision. Overall, the GAF scores reflected in the evidence do not appear to be consistent with the reported and objectively observed symptoms that are discussed above. In that regard, there is no evidence that the Veteran demonstrated a consistently flat affect or any abnormalities in his speech. As noted above, the evidence showed that the Veteran appeared to maintain a relatively high level of social and occupational functioning, despite the deterioration of his marriage, which was not shown as being attributable to his PTSD. Under the circumstances, in assessing the severity of the Veteran's PTSD prior to February 5, 2009, the Board assigns far greater probative weight to the subjective complaints and objective findings noted in the medical evidence than it does to the assigned GAF scores. Accordingly, the Board finds that the Veteran's symptomatology is consistent with a 30 percent disability rating under DC 9411 for the period before February 5, 2009. To that extent, this appeal is denied. B. From February 5, 2009 through February 28, 2010 As noted above, the RO's February 2010 SOC awarded the Veteran a higher 50 percent disability rating for PTSD, effective from February 5, 2009. This disability rating continued without interruption until an August 2010 rating decision which granted a temporary 100 percent disability rating for PTSD, effective from March 1, 2010, on the basis of in-patient treatment for PTSD that began on March 1, 2010. In that posture, the Board must consider whether the Veteran is entitled to a disability rating for PTSD higher than 50 percent for the period from February 5, 2009 through February 28, 2010. In his February 2009 claim, the Veteran alleged that his PTSD was deteriorating due to increasing nightmares and inability to sleep. He also stated that he preferred staying at home and not dealing with people. During VA treatment in March 2009, the Veteran reported that he was feeling more depressed and was growing increasingly dissatisfied with his job. During a VA examination performed in March 2009, the Veteran reported that his PTSD symptoms had been generally increasing. In that regard, he reported sleep problems marked by increasing nightly nightmares and sleeping only three to four hours per night. He also reported increasingly depressed mood over the past two years; daily anger; fleeting suicidal thoughts over the last couple of years, although increasing recently in frequency to a near daily basis; increasing marital stress, financial strain; and work stress. Despite his reportedly increasing suicidal thoughts, he stated that he did not have specific plan and stated that he would not act on his suicidal thoughts. Occupationally, he reported that he had been working as an assistant principle since August 2008 and that he was required to inhibit his desire to yell and physically assault his students. He also reported that he had lost his previous job as a school administrator in June 2008 after being accused of having an extramarital affair by the school board. Overall, the Veteran reported having greater social impairment at work and that he was struggling with interactions and with resolving conflicts with others. He also reported an increase in anger and irritability which led to problems at work and to his losing his prior job in June 2008 due to a decline in work performance, all of which he attributed to PTSD. Socially, the Veteran reported that he was separated from his spouse. He stated that he had three sons and one daughter and that he had contact with his sons approximately once a month and that he saw his daughter once every three weeks. He described his relationships with his children as being fair to good, but stated that otherwise he preferred being alone and did not have any desire to socialize often. Despite the same, he also stated during the examination that he was having a relationship with a woman in South Dakota and that he enjoyed leisure activities such as caring for his dog and two parrots. Reported decline in psychosocial activity over the last couple of years, but stated that he was able to take care of routine responsibilities of self-care. Overall, the examiner opined that the Veteran had very few social relationships and did very little with his leisure time. During mental status examination, the Veteran demonstrated dysphoric mood with a depressed affect. Although demonstrated thought process was goal-oriented overall, the examiner did not that there was an apparent overabundance of ideas. Demonstrated speech was slow in rate and rhythm and the Veteran spoke softly at times. Also demonstrated psychomotor activitiy was observed as being lethargic and fatigued. The remaining portions of the mental status examination, however, were apparently within normal limits. In that regard, there was no noted abnormality in the Veteran's appearance and hygiene. There was no evidence of delusions, hallucinations, suicidal ideation, or homicidal ideation. The Veteran was oriented to person, place, time, and situation. His responses to phrases requiring abstract thinking and comprehension were appropriate. He was able to perform serial seven exercises, thus indicating normal concentration, and also demonstrated intact immediate, recent, and remote memory. He demonstrated insight and awareness of his problems. Finally, the examiner did not observe any evidence of impairment of thought process or communication; inappropriate behavior; obsessive or ritualistic behavior that would interfere with routine activities; or irrelevant, illogical, or obscure speech patterns. Overall, the examiner determined that, although the Veteran reported that he struggled to perform some activities of daily living during periods of depression, the Veteran did demonstrated the ability to perform his basic activities of daily living. In summarizing the findings from the examination, the examiner stated that, overall, the Veteran reported an increase in irritability, anger, social isolation, and intrusive thoughts of traumatic experiences. The examiner opined that socially, the Veteran spent most of his time at home and was occasionally visited by family and two other friends. He opined that the Veteran's depression was secondary to PTSD and that the most bothersome of the Veteran's symptoms were sleep impairment and increasing nightmares. Based upon the findings from the examination, the examiner assessed a GAF score of 60 and opined that the increase in the Veteran's PTSD symptoms resulted in reduced reliability and productivity in occupational social functioning due to symptoms such as increased irritability, anger, sleep impairment, and social isolation. During VA treatment in April 2009, the Veteran reported ongoing nightmares, moderate to severe anhedonia, and difficulty concentrating and making decisions, as well as new symptoms of poor motivation to get out of bed in the morning. Occupationally, the Veteran apparently reported that he was still working and stated that he was contemplating retirement. During mental status examination, the Veteran demonstrated slightly euthymic mood with congruent slightly restricted affect. The remaining mental status examination, however, was grossly normal. In June 2009, subjectively reported symptoms included worsening sleep patterns, crying, ongoing difficulty concentrating and making decisions, hypervigilance, nightmares, anxiety, poor motivation, and ongoing grief over a recently ended relationship. During mental status examination at that time, the Veteran continued to demonstrate melancholic mood with congruent and slightly restricted affect. Nonetheless, the remaining examination remained within normal limits. In his July 2009 NOD, the Veteran appeared to indicate difficulty holding jobs, as he alleged that he had a history of being transient and moving from job to job. He reported that he experienced difficulty focusing, constant depression, decreased sleep of three or four hours per night, frequent anxiety attacks, sensitivity to loud sounds, being suspicious of others and being unable to become close to others, being suspicious of authority, and having emotional difficulty around specific times of the year, such as anniversary of combat dates. He also reported difficulty starting new relationships and having suicidal ideation. During VA treatment in September 2009, the Veteran reported that he was having daily suicidal ideation and that he practiced suicide by putting a gun into his mouth and to his throat. He also made ongoing complaints of depression, nightmares, avoidance of things that remind him of stressors, being sensitive to loud noises, and feeling detached from others and activities. Based upon the Veteran's reported symptoms, he was placed in an outpatient suicide prevention program. A GAF score of 50 assigned. In October 2009, the Veteran underwent a new VA examination which was performed by the same VA examiner who performed the prior March 2009 examination. During the October 2009 examination, the Veteran reported ongoing symptoms of sleep disturbance marked by disrupted sleep, waking early, and nightmares; intrusive thoughts of traumatic experiences; increased depression, particularly after ending his relationship with his girlfriend in June 2009; anger and irritation; and fleeting suicidal thoughts. He stated that he experienced problems with some activities of daily living, but did not specify which aspects of his activities presented problems. He reported an overall decline in psychosocial functioning since his prior March 2009 examination. Occupationally, the Veteran reported that he had not worked since June 2009 and that he was looking for new employment as a school administrator. He stated that he did not believe that he would ever be able to work with children again, apparently based upon difficulty with anger and frustration in his prior job as an assistant principal. He estimated missing two to three days of work a month due to an increase in his PTSD symptoms. He stated that, over the last two weeks, he was able to work as a truck driver for a farmer. Socially, the Veteran reported that he maintained a good relationship with one son and fair to good relationships with his daughter and other two sons. He stated that he was seeing his daughter more frequently and that he babysat her children over the summer. He also reported having supportive friends who also served in the military. In terms of leisure activities, he continued to report that he enjoyed visiting with friends and caring for his dog and two parrots. During the mental status examination, the Veteran demonstrated mildly lethargic and fatigued activity level with dysthymic mood and congruent affect. Nonetheless, the remainder of the examination was apparently within normal limits. In that regard, the examiner noted that there was no evidence of impairment of thought process or communication; inappropriate behavior; problems with the ability to maintain hygiene; obsessive or ritualistic behavior that interfered with routine activities; or problems with speech (such as irrelevant or illogical speech or obscure speech patterns). Moreover, the Veteran was oriented to person, place, time, and situation, was able to perform serial seven exercises, and demonstrated intact immediate, recent, and remote memory. The Veteran's insight and awareness of his mental problems was fair. In summarizing the Veteran's symptomatology, the examiner opined that the Veteran appeared to experience actual reduction in his anger and nightmares, per the Veteran's own subjective report. The examiner also noted that the Veteran was demonstrating problems with his social relationships, but, still was able to form supportive relationships with some friends. The examiner also noted that the Veteran continued to have problems with anxiousness and intrusive thoughts, particularly in relation to anniversary dates of his combat and traumatic experiences in Vietnam. Overall, the examiner opined that these symptoms are related to PTSD and depressive disorder and determined that the Veteran's depressive disorder, which was independent of his PTSD, resulted in decreased quality of life due to loneliness. The examiner determined that the Veteran's PTSD mostly continued at the same level from his previous examination. Regarding the Veteran's depression, the examiner opined that it appeared to be the result of the breakup of his relationship with his girlfriend in June 2009 and the loss of his job as assistant principal. The examiner opined further that the Veteran's increased financial burden resulting from his job loss also contributed to his depression. That being said, the examiner noted that the Veteran continued to have problems with anger and irritability in work settings and that this required him to repress his anger and take days off from work. As noted above, the Veteran did not believe himself capable of being employed in a school setting where he had frequent interactions with teachers and students. Taking into consideration both diagnoses of PTSD and depression, the examiner assessed a GAF score of 58; however, determined that the Veteran's GAF score, attributable to PTSD alone, was 62. During VA treatment in December 2009, the Veteran continued to report having nightmares and intrusive thoughts, and, reported that these symptoms were triggered recently by the death of a service buddy. Despite these complaints, the Veteran also reported improved energy level, sleep, and motivation, as well as mildly less depression and less difficulty with concentration. A GAF score of 45 was assessed. A repeated mental status examination performed in February 2010 did not reveal any changes. The evidence from February 5, 2009 through February 28, 2010 reflects symptomatology that is consistent with a 50 percent disability rating, and no more, under the General Formula. In that regard, the relevant evidence reflects PTSD symptoms which include ongoing anxiety; sleep problems marked by recurring nightmares; anger; suicidal ideation; lethargic psychomotor activity; slowed speech rate; anhedonia; flattened affect; a degree of social isolation; and some difficulty in adapting to stressful circumstances, as indicated by the Veteran's admission that he did not believe himself capable of working in a school setting around students and teachers due to his anger and irritability. Other than the Veteran's suicidal ideations and difficulty in adapting to stressful circumstances, which have both been considered as part of the basis for the assigned 50 percent disability rating for the period at issue, the evidence simply does not show the presence of any symptoms that are identified under the General Formula as being consistent with a higher disability rating. In that regard, there is no evidence of obsessional rituals which interfere with routine activities; illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the Veteran's ability to function independently, appropriately, and effectively; impaired impulse control such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance or hygiene; or total inability to establish and maintain effective relationships. Similarly, there is no evidence that the Veteran's PTSD has resulted in any delusions or hallucinations; grossly inappropriate behavior; intermittent inability to perform activities of daily living disorientation to time or place; or memory loss to the degree that the Veteran was unable to recall the names of close relatives, his own name, or his occupation. Insofar as the Veteran's depression, VA examinations indicated that such symptoms were manifestations of a separate depression disorder that was independent of the Veteran's service-connected PTSD. This conclusion is not contradicted by any evidence to the contrary, and indeed, appears to be consistent with the Veteran's psychiatric and social history. Socially, the evidence shows that the Veteran was experiencing ongoing problems in his social interactions. In that regard, the evidence shows that the Veteran maintained few friends and experienced difficulty interacting in his work setting as a school principal. Nonetheless, the evidence also continued to show that the Veteran was capable of maintaining a meaningful relationship, as evidenced by his ongoing relationships with his children and grandchildren and his expressed grief over the loss of his relationship with his girlfriend. Although the Veteran expressed some difficulty in working in a school setting, and the veteran was apparently unemployed for part of the appeal period at issue, there is no indication in the record that the Veteran experienced deficiencies or outright inability to perform occupational duties, or, that his inability to find new work was due in any way to his PTSD symptoms. In that regard, the VA examiner determined in his March 2009 and October 2009 opinions that the Veteran's symptoms were resulting in only reduced reliability and productivity in occupational functioning. During the appeal period at issue, the Veteran's GAF scores ranged broadly from a low score of 45 (provided during December 2009 VA treatment) to 60 (provided during the Veteran's March 2009 VA examination). The Board notes that the Veteran's most recent GAF score during the period at issue was 58, as determined at his October 2009 VA examination. As noted above, a GAF score falling in the range of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). GAF scores falling in the range of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). Subject to the Board's discussion concerning GAF scores in the preceding section, the Veteran's symptomatology appears to be in line with the lower GAF scores ranging between 41 to 50 (in this case, to include GAF score of 50 during VA treatment in September 2009 and 45 during December 2009 VA treatment). Although the Board is inclined to find that the Veteran's symptomatology during the period at issue is more in line with the lower range from 41 to 50 the Board also finds that the assigned GAF scores falling in that range are consistent with the assignment of a 50 percent disability rating and do not suggest the presence of symptomatology which warrants a 70 percent disability rating under the General Formula. Accordingly, the Board finds that the Veteran's symptomatology is consistent with a 50 percent disability rating under DC 9411 for the period from February 5, 2009 through February 28, 2010. To that extent, this appeal is denied. C. From May 1, 2010 As discussed above, an August 2010 rating decision granted a 100 percent disability rating, due to hospitalization for treatment of PTSD, effective from March 1, 2010 through April 30, 2010. Under that same rating decision, the disability rating for the Veteran's PTSD was to return to 50 percent, effective from May 1, 2010. That disability rating has continued unabated. In that posture, the Board now considers whether the Veteran is entitled to a disability rating higher than 50 percent for PTSD from May 1, 2010. During VA treatment from May 2010, the Veteran reported having a stable mood and denied having any current suicidal ideation. A mental status examination performed at that time did not reveal any new findings in relation to previous examinations. During follow-up treatment in June 2010, the Veteran appeared to endorse stress related to recent flood damage to his home. Nonetheless, a mental status examination performed that that time also did not reveal any changes or new findings. During a June 2010 VA examination, the Veteran reported symptoms which included chronic sadness; anxiety; irritable mood with low energy; low concentration; isolative behavior; avoiding crowds with panic attacks in crowds; nightmares; and frequent awakening from his sleep. Occupationally, he reported that he had not worked since May 2009 when he worked as a high school principal. He related that he was fired from that job due to a lack of concentration and being ineffective on the job. Socially, he reported that he maintained a good relationship with his adult children despite his reported irritability. He stated that he had difficulty keeping up with his grandchildren due to decreased energy levels. He continued to report having friends socially, but stated that he preferred being socially isolated and avoided crowds. He stated that he enjoyed leisure activities such as reading, babysitting his grandchildren (despite reported difficulty in keeping up with them), and working on the computer. Findings from the mental status examination revealed new findings of decreased recent memory; however, were otherwise essentially consistent with the findings from previous examinations dating from 2009 through the date of the VA examination. In that regard, the Veteran was again casually dressed and made occasional eye contact with the examiner. His speech rate continued to be slow with normal coherence and normal spontaneity. The Veteran continued to admit occasional thoughts of suicide but denied having any definite plan or intent. His affect remained mildly restricted. Demonstrated thought processes were logical with normal communication. Associations were intact. There was no evidence of hallucinations, delusions, obsessions, or compulsions. A cognitive examination revealed that the Veteran remained oriented to time, person, and place. Attention and concentration were acceptable and the Veteran was able to perform serial three exercises. Impulse control, judgment, and insight were also acceptable. The examiner observed that the Veteran remained able to maintain personal hygiene and perform basic activities of daily living. Overall, the examiner opined that the Veteran's PTSD was manifested by chronic and nightly nightmares; flashbacks triggered by loud noises and certain smells; recurrent intrusive recollections avoidance of thoughts and feeling associated with combat trauma; avoidance of activities and situations that might arouse recollections of trauma; markedly diminished interest in activities and feelings of estrangement or detachment from others; and sense of foreshortened future, hypervigilence, and exaggerated startle responses. A GAF score of 50 was assigned. Overall, the examiner opined that the Veteran's PTSD symptoms resulted in considerable impairment of functional status, quality of life, and employment with reduced reliability and productivity. During VA treatment in July and August of 2010, the Veteran continued to report having a stable mood. Indeed, during his August 2010 evaluation, he reported that he was feeling better since the flood damage to his home dried. The Veteran continued to report ongoing sleep disturbances; however, mental status examinations did not reveal any significant changes. During VA treatment in September 2010, the Veteran reported that he was busy with research work and that he was working as a part time college instructor. Socially, he stated that he spent quality time with his grandchildren during the summer. He continued to deny having any present suicidal ideation, but reported ongoing nightmares and new symptoms of moderate and recurrent daytime intrusive thoughts. Despite these reported complaints, the Veteran's mental status examination was grossly normal. Subsequent VA treatment records through December 2010 continue to reflect complaints of sleep disturbances, but no significant changes in the Veteran's mental status. During VA evaluation and treatment in January 2011, the Veteran reported that he was feeling good. Socially, he reported that he recently went out to eat with a woman and that it was fun and felt good. He also reported that he enjoyed spending time with his family and grandchildren and that he spent time at his son's home during Christmas. A mental status examination again did not reveal any changes. A GAF score of 60 was assigned. In February 2011, the Veteran continued to report ongoing employment and to indicate a relatively high level of social functioning. In that regard, he stated that a colleague at the university had arranged an introduction with a woman and that he intended to pursue this social opportunity. Once again, he denied suicidal ideation and reported that he was spending much of his time with his grandchildren. A mental status examination revealed essentially unchanged findings. During a follow-up visit in March 2011, he reported that his mother had recently passed away, but, that he continued to have a very close relationship with his family. Mother recently passed away. A repeat mental status examination did not reveal any new findings. A GAF score of 60 was assigned. Based upon the foregoing evidence, the Veteran is also not entitled to a disability rating in excess of 50 percent for PTSD for the period from May 1, 2010. In that regard, the evidence shows that the Veteran continued to experience symptoms of sleep disturbance marked by nightmares; flashbacks triggered by loud noises and certain smells; recurrent intrusive recollections avoidance of thoughts and feeling associated with combat trauma; avoidance of activities and situations that might arouse recollections of trauma; markedly diminished interest in activities and feelings of estrangement or detachment from others; a sense of a foreshortened future; hypervigilence; and exaggerated startle responses. The Veteran repeatedly denied having any current suicidal ideation, and in comparison to the prior appeal period at issue, demonstrated an improved ability for adapting to stressful circumstances. In that regard, the Board notes that the Veteran consistently reported a relatively high level of social function and that he was able to maintain employment at a university research and teaching position. Indeed, the evidence for the period from May 1, 2010 again does not indicate any PTSD symptoms that are identified under the General Formula as being consistent with a disability rating higher than 50 percent. In that regard, there continues to be no evidence of obsessional rituals which interfere with routine activities; illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the Veteran's ability to function independently, appropriately, and effectively; impaired impulse control such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance or hygiene; or total inability to establish and maintain effective relationships. Similarly, there is no evidence of delusions or hallucinations; grossly inappropriate behavior; intermittent inability to perform activities of daily living disorientation to time or place; or memory loss to the degree that the Veteran was unable to recall the names of close relatives, his own name, or his occupation. As noted above, the Veteran was assigned a GAF score of 50 during his June 2010 VA examination. During subsequent VA treatment through March 2011, the Veteran's GAF score was consistently and repeatedly rated as 60. For ease of reference, the Board notes again here that a GAF score falling in the range of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). GAF scores falling in the range of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). The symptomatology shown in the evidence since May 1, 2010 appears to be more consistent with the GAF scores of 60 assessed during the Veteran's VA treatment than it is with the score of 50 assigned during the VA examination. In that regard, the Veteran has consistently denied having any current suicidal ideation and reported, both during his VA examination and during VA treatment, that he maintained social relationships and close relationships with his family. Although the Veteran related during his VA examination that he was unemployed at that time, he did report enjoyment in various leisure activities which included working on his computer. Indeed, the subsequent VA treatment records show that the Veteran was able to secure and maintain employment as a researcher and instructor in a university position. In view of the foregoing, and the apparent extent of the Veteran's social functioning, the Board finds that the assigned GAF scores of 60 during VA treatment are more consistent with the Veteran's symptomatology, and moreover, are not consistent with a disability rating higher than 50 percent under the General Formula. Accordingly, the Board finds that the Veteran is not entitled to a disability rating higher than 50 percent for PTSD for the period from March 1, 2010. To that extent, this appeal is denied. D. Other Considerations The Board has also considered the provisions under 38 C.F.R. § 3.321(b)(1), which govern the assignment of extra-schedular disability ratings. However, in this case, the record does not show that the severity of the Veteran's PTSD is so exceptional or unusual such as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and, no extra-schedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular rating does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show that the Veteran's PTSD presents an exceptional disability picture that renders inadequate the available schedular ratings. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As discussed above, higher disability ratings are available under the General Formula; however, the Veteran's PTSD is not productive of a symptomatology that is consistent with the assignment of a higher disability rating. As such, it cannot be said that the available schedular ratings for the Veteran's PTSD are inadequate. Based on the foregoing, the Board finds that the requirements for an extra-schedular evaluation for the Veteran's service-connected PTSD, under the provisions of 38 C.F.R. § 3.321(b)(1), have not been met. Thun, 22 Vet. App. 111; Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). The Board has also considered whether "staged" disability ratings, beyond those already provided, are warranted by the evidence. The symptomatology shown upon examination and treatment, however, has been essentially consistent and fully contemplated by the assigned disability ratings. As such, there is no basis for further staged disability ratings in connection with the Veteran's PTSD. ORDER Entitlement to an increased disability rating for posttraumatic stress disorder (PTSD) rated as 30 percent disabling, prior to February 5, 2009, is denied. Entitlement to an increased disability rating for PTSD rated as 50 percent disabling, from February 5, 2009 through February 28, 2010, is denied. Entitlement to an increased disability rating for PTSD rated as 50 percent disabling, from May 1, 2010, is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs