Citation Nr: 1334363 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 07-34 814 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to March 20, 2008. 2. Entitlement to a rating in excess of 70 percent for PTSD, since May 1, 2008. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from November 1966 to November 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from April and September 2006 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In the April 2006 rating decision, the RO granted service connection and assigned an initial 30 percent rating for PTSD, effective January 26, 2006. In the September 2006 rating decision, the RO continued the 30 percent initial rating. In a September 2008 rating decision, the RO granted a temporary total rating for PTSD because of hospitalization over 21 days, effective March 20, 2008. A 70 percent rating was assigned effective May 1, 2008. 38 C.F.R. § 4.29 (2013). Despite the grant of a higher rating following termination of the temporary total rating, the Veteran has not been awarded the highest possible evaluation, and his claim remains in appellate status. A.B. v. Brown, 6 Vet. App. 35 (1993). In June 2011, the Board remanded the claim for a higher initial rating for PTSD to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. After completing the additional development, the AMC denied the claims for higher ratings (as reflected in a September 2012 supplemental statement of the case (SSOC)), and returned these matters to the Board. In June 2011, the Board found that while a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) had been denied in an August 2007 rating decision, the Veteran had since submitted evidence of unemployment. The Board instructed the AMC/RO to again consider whether the Veteran was entitled to a TDIU, citing Rice v. Shinseki, 22 Vet. App. 447 (2009). In the September 2012 SSOC, the Veteran was awarded a TDIU in the September 2008 rating decision. That rating decision granted a TDIU effective May 15, 2008. The record reflects that the Veteran stopped working on March 17, 2008. The question of entitlement to a TDIU during the period from March 20, 2008 to May 1, 2008 is rendered moot as a result of the temporary total rating assigned during that period. While the Veteran was apparently unemployed for two days prior to this period of temporary total rating, compensation is paid on the first day of the month following the effective date, i.e., April 1, 2008. See 38 C.F.R. § 3.31 (2013). Thus, this two day difference is a moot point as no earlier payment would be made. Similarly, while the Veteran was unemployed and not in receipt of a total rating from May 1, 2008 to May 15, 2008 because payment of compensation begins the first of the month following the effective date, award of a TDIU during this period would not result in payment of compensation for a TDIU prior to June 1, 2008. Id. The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence that has been considered by the RO in the most recent supplemental statement of the case (SSOC). Therefore, the Board's consideration of this evidence will not result in prejudice to the Veteran. The September 2013 Informal Hearing Presentation (IHP) from the Veteran's representative is also included in the Virtual VA e-folder, and has been considered in the adjudication of these claims. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claims on appeal has been accomplished. 2. Beginning the date of claim (prior to March 20, 2008), the Veteran's PTSD was manifested by symptoms indicative of occupational and social impairment with reduced reliability and productivity. 3. Since May 1, 2008, the Veteran's PTSD is not shown to be productive of total occupational and social impairment. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, prior to March 20, 2008, the criteria for an initial rating of 50 percent, but no more, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.130, Diagnostic Code 9411 (2013). 2. Since May 1, 2008, the criteria for a rating in excess of 70 percent for PTSD have not been met or approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duty to Notify and Assist The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (Court) have been fulfilled. The Veteran filed a request to reopen his claim for service connection for PTSD in June 2005. He was notified of the general provisions of the VCAA by the RO in correspondence later that month. This letter notified the Veteran of VA's responsibilities in obtaining information to assist him in completing his claim, identified the Veteran's duties in obtaining information and evidence to substantiate his claim, advised him of the information and evidence needed to substantiate the underlying claim for service connection for PTSD, and provided other pertinent information regarding the VCAA. Thereafter, the claim was reviewed and the RO issued the April 2006 rating decision granting service connection for PTSD. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). The claim for a higher initial rating for the Veteran's service-connected PTSD is a downstream issue, which was initiated by a notice of disagreement. The Court has held that, as in this case, once a notice of disagreement from a decision establishing service connection and assigning the rating and effective date has been filed the notice requirements of 38 U.S.C.A. §§ 5104 and 7105 control as to the further communications with the appellant, including as to what "evidence [is] necessary to establish a more favorable decision with respect to downstream elements...." Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Hence, there is no duty to provide additional VCAA notice in this case. Regardless, the RO sent the Veteran additional VCAA notice letters in April and November 2007 which informed him of the information and evidence necessary to substantiate a claim for a higher rating for PTSD. The Court, in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), held that the VCAA notice requirements apply to all elements of a claim. Notice as to these matters was provided in a March 2006 letter and in the April and November 2007 VCAA letters. The Veteran has been made aware of the information and evidence necessary to substantiate his claims and has been provided opportunities to submit such evidence. A review of the claims file and Virtual VA e-folder shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claims during the course of this appeal. His VA treatment records have been obtained and associated with his claims file/e-folder, and his private psychologist has submitted several letters in support of his claims. The Veteran was also provided with VA examinations to evaluate his service-connected PTSD in February 2006, May 2007, February 2008, and March 2012. The claim for a higher initial rating for PTSD was remanded in June 2011 in order to obtain additional VA treatment records, afford the Veteran a new VA examination to evaluate his PTSD, give the Veteran the opportunity to provide authorization for the release of records from his private psychologist, Dr. L.J-M., and so that the RO could consider whether the Veteran was entitled to a TDIU. The additional VA treatment records identified in the June 2011 remand were obtained and associated with the e-folder. The Veteran underwent VA examination to evaluate his PTSD in March 2012, with an addendum opinion provided in May 2012. The March 2012 examination report is responsive to the pertinent rating criteria. Thus, this examination reports is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). A May 2008 VCAA letter regarding the Veteran's claims for a temporary total rating and a TDIU states that a consent and release he had submitted regarding treatment records from Dr. L.J-M. did not contain an address or contained an incorrect address. The RO asked the Veteran to provide this address so medical information could be requested. The claims file does not reflect that the Veteran subsequently furnished a complete release form. In a November 2011 letter, the RO asked the Veteran to complete and return a VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for each health care provider so VA could obtain records on his behalf. The RO specifically noted that the Veteran had reported receiving treatment from Dr. L.J-M. The Veteran did not subsequently provide a release to allow VA to obtain treatment records from this psychologist. VA is only obligated to obtain records that are adequately identified and for which necessary releases have been received. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Moreover, a claimant has the responsibility to present and support a claim for benefits under laws administered by the VA, 38 U.S.C.A. § 5107(a). While VA has a duty to assist the veteran in substantiating his claim, that duty is not a one- way street. Woods v. Gober, 14 Vet.App. 214, 224 (2000); see also Hurd v. West, 13 Vet.App. 449, 452 (2000) (the Veteran cannot passively wait for help from VA). As the Veteran has not provided an adequate release form regarding his private psychological records, it is not possible for VA to obtain them; hence, no further action in this regard is warranted. The Veteran has not identified any additional, relevant evidence that has not been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claims, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claims. The Merits of the Claims Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Where the question for consideration is entitlement to a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Veteran's PTSD is evaluated pursuant to Diagnostic Code 9411. The criteria for rating psychiatric disabilities other than eating disorders are set forth in a general rating formula. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. Under the formula, a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting 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. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association : Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, GAF scores must be weighed alongside all additional relevant evidence. See, e.g., Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet App. 429, 433 (1995) (it is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others). The terms "mild," "moderate," "moderately severe" and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R § 4.6. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Medical evidence of record reflects diagnoses of and treatment for depression and PTSD. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the veteran's service-connected disability. Mittleider v. West, 11 Vet. App. 181 (1998). There is no indication that it is possible to distinguish the symptoms from the Veteran's depression, and PTSD as described in the evidence of record. Accordingly, the Board has considered all of the pertinent symptoms described in the treatment records in evaluating the Veteran's service-connected PTSD. Considering the pertinent evidence of record in light of the law, and resolving all reasonable doubt in favor of the Veteran, the Board finds that an initial 50 percent rating for service-connected PTSD, prior to March 20, 2008, is warranted, but that a rating in excess of 70 percent since May 1, 2008 is not warranted. Prior to March 20, 2008 In a January 2006 letter, the Veteran's private psychologist, Dr. L. J-M., wrote that the Veteran was under her care for PTSD. She reported that he experienced multiple symptoms of PTSD, including but not limited to intrusive recall of events that occurred in Vietnam, flashbacks and episodes of dissociation, nightmares, nightsweats, dreams from which he awakened abruptly and felt frightened, hypervigilance, irritability and outbursts of anger, and extreme distress at cues/reminders of his experiences during war. She noted the Veteran's report of worsening of PTSD symptoms since being afflicted with diabetes mellitus and other medical conditions, and stated that he described himself as "more tense than ever." The Veteran also reported that worsening of his sleep as a result of dreams and nightmares of Vietnam had contributed to a worsening of his irritability and anger. He commented that his problems with anger were "[h]appening even at work." Dr. L. J-M. noted that the Veteran had been employed at a car dealership for 19 years and, because of his long history with the company, they had been tolerant of his shifts in performance. She added that it was, however, a source of distress to the Veteran that he was increasingly "moody" and his behavior felt unpredictable; noting that the stress of his medical problems and job-related stress had resulted in a vicious cycle which continued to worsen his PTSD. Dr. L. J-M. reported that the Beck Depression Inventory (BDI) administered in October 2005 placed the Veteran in the severely depressed range, and more recent administration of this test indicated that his depression continued to worsen. She concluded by noting that the Veteran was in treatment for chronic PTSD as well as depression secondary to diabetes, nephropathy, and neuropathy. She assigned a GAF score of 50 and commented that the Veteran experienced significant occupational impairment as a result of PTSD. The Veteran was afforded a VA PTSD examination in February 2006. He described current symptoms including poor sleep, with nightmares related to his combat experiences occurring two to four times a week. He described himself as irritable and reported difficulty getting along with others. He recounted one incident in which he became enraged at his wife; found her at her sister's house; and was going to kill her and her sister and his brother-in-law. The Veteran reported that, after this incident, he got rid of all his weapons and began to seek treatment, noting that he had been in treatment for six months. In discussing his previous psychiatric history, the Veteran did report some instances of homicidal ideation, but denied that he had ever tried to harm anyone. He denied suicidal ideation or plan. Regarding his occupational history, the Veteran reported being employed as a car salesman for 19 years. He described fluctuating levels of performance, but reported that he had a good relationship with his supervisor and was allowed to leave whenever he became extremely irritated. Regarding his social history, the Veteran reported that he had been married for 36 years and had five children and seven grandchildren. He stated that he saw his family frequently. He described limited recreational activities and social supports. On mental status examination, the Veteran was well-dressed and appropriately groomed. Speech was clear, coherent, and goal-directed, and he was oriented to time, place, and person. Thought processes were clear and devoid of delusional content. Affect was blunted and mood was dysphoric. The Veteran did not make any significant eye contact during the evaluation. Insight and judgment were well-developed and there was no evidence of any thought or perceptual disturbance. The Axis I diagnosis was PTSD and the examiner assigned a GAF score of 45. The examiner commented that the Veteran was experiencing a mild level of impairment in social and occupational functioning. In August 2006, Dr. L.J-M. indicated that the reported incident of the Veteran flying into a rage at his wife was consistent with homicidal ideation with some indication of intent and grossly inappropriate behavior. She also stated that the Veteran's report of fluctuating levels of work performance with an ability to leave work whenever he became extremely irritated, as reported during the February 2006 VA examination, was consistent with reduced reliability and productivity as well as difficulty in adapting to stressful circumstances, including work. Dr. L.J-M. stated that the GAF score of 45 as assigned during the VA examination indicated serious symptoms and serious impairment in social and occupational functioning. Therefore, she opined that the February 2006 VA examination findings were consistent with a disability rating in excess of 30 percent for PTSD. Dr. L.J-M. described the findings on the VA examination as consistent with her evaluation of the Veteran's condition. She opined that, as a result of serious and severe symptoms of PTSD, the Veteran experienced serious impairments in both social and occupational functioning. She commented that the Veteran's ability to be reliable and productive in his work as a car salesman had been steadily on the decline and attributed his ability to remain working with his employer to his long work history and the employer's willingness to tolerate/accommodate his need to leave work when he became extremely anxious and/or irritable. Dr. L.J-M. noted that the Veteran's job involved a lot of standing, which resulted in leg swelling at the end of the day. She opined that, because of his Agent Orange related diabetes and peripheral neuropathy, which resulted in painful swelling in the legs, the Veteran was continually reminded of his experiences in Vietnam and the decline of his medical condition as a result of his service there, which served to facilitate recall of combat and escalate his anxiety and irritability. Dr. L.J-M. reported a current GAF score of 48. Dr. L.J-M. included with her August 2006 letter a statement discussing the VA rating criteria for mental disorders as compared to the DSM-IV. She asserted that none of the specific symptoms of PTSD appeared in the list of sample criteria for a 100 percent rating. She continued, however, to state that specific symptoms of PTSD, such as flashbacks, can include hallucinations and disorientation to time and space, and symptoms of PTSD could facilitate behaviors that were grossly inappropriate and presented a danger of hurting self or others. She opined that a person experiencing PTSD symptoms which included persistent flashbacks during which visual, auditory, olfactory, or tactile hallucinations occurred or which included episodes of dissociation during which there was a disruption in orientation to time and place would be experiencing impairment likely consistent with the 100 percent rating. VA treatment records dated from January 2006 to March 2007 reflect diagnoses of and treatment for PTSD and major depression. On mental health intake assessment in January 2006, the Veteran reported that a lack of sleep caused him the most problem. He stated that he was always tired and exhausted and had little motivation. He added that he had begun to feel depressed and had been reclusive with few activities with family. He denied suicidal or homicidal thoughts. He reported feeling alone and not wanting to be bothered, which interfered with his work selling cars. Mood was sad and depressed and affect was constricted. The Veteran reported that he and his wife had some difficulty due to his PTSD and depression. In completing the intake assessment, the counselor was asked to indicate by marked box all applicable presenting problems. He marked that the Veteran had PTSD, depression, and insomnia, but did not mark anxiety, panic attacks, psychosis, hallucinations, delusions, bizarre behavior, or suicidal/homicidal ideation. On examination, mood was sad and depressed. Concentration was fair. Recent and remote memory were good. The Veteran denied suicidal/homicidal ideation or plan. The provisional diagnosis was PTSD/depression. The Veteran's January 2006 initial treatment plan notes his strengths to be his intelligence, judgment, and communication skills. His problems were an inability to sleep at night and being depressed most of the time. He stated that his depression affected his ability to work. On the same date, the Veteran was examined for a medication evaluation. His chief concerns were recorded as being "kind of down, depressed, not able to sleep." On mental status examination, mood was anxious and affect was mildly constricted. Speech was normal rate and tone and spontaneous. Sleep was poor and energy and interests were decreased, but appetite was good. Thoughts were coherent and goal-directed. There were no psychotic, delusional, suicidal, or homicidal thoughts and the Veteran denied suicidal or homicidal plans and he was described as being neither a suicidal nor a homicidal risk. The diagnosis was PTSD. A GAF score of 48 was assigned. When the Veteran saw his counselor the following month, he reported very little improvement in his depression which was causing him problems at work and at home. The Veteran stated that he was isolating, did not want to go out, and was not very active, although he walked several miles every morning. The counselor commented that the Veteran did not take enough time off from work, which was a stressor for him. He denied suicidal/homicidal thoughts. Mood was very sad and depressed and affect was flat. In March 2006, the Veteran reported that he was taking his medications as prescribed and was feeling better, with an improvement in his depression. He stated that he still had some PTSD symptomatology that was causing him some difficulty. He reported that he was taking better care of himself. He denied suicidal/homicidal ideation. In April 2006, the Veteran reported to his counselor that he was having difficulty with motivation and had some sleep pattern disruption. He stated that he was having difficulty with work and was not selling as much as previously. He reported that he was isolating more, was staying away from people, and was staying in his office more. During mental health treatment with his physician later that day, the Veteran reported that he felt "good just down a bit." On mental status examination, the Veteran was alert, cooperative, and verbally interactive. Mood was anxious and affect was mildly constricted. Speech was normal rate and tone and spontaneous. Energy and interests were decreased, but appetite was good. Thoughts were coherent and goal-directed. There were no psychotic, delusional, suicidal, or homicidal thoughts and the Veteran denied suicidal or homicidal plans and he was described as being neither a suicidal nor a homicidal risk. The diagnosis was PTSD. A GAF score of 42 was assigned During mental health treatment in June 2006, the Veteran stated that his depression had improved. He reported that he had been on vacation and had had a good time. He stated that his symptoms of depression had decreased to the point that he was more effective in most aspects of his life and was more active and involved. He indicated that his motivation had improved, as had his sales at work. He reported that he was still struggling with a lack of energy, although he was trying to address these symptoms with diet and exercise. In August 2006, the Veteran reported that his depression was still causing him difficulty in his personal life and at work. He reported being unable to stay focused on his work and was irritable, very negative, and very unhappy. He reported feeling sad and having difficulty in interactions with his wife. Although she was trying to be understanding, he described the situation as difficult for both of them. The Veteran reported struggling in his work as a salesman because it was difficult to present himself to the public as happy when he was sad. He added that he had little energy to put into work. The Veteran denied suicidal ideation and homicidal ideation. In November 2006, the Veteran indicated that he had trouble sleeping and experienced some flashbacks and nightmares, but reported that he was eating well and his medicines seemed to "help some." In March 2007, the Veteran stated that he was not sleeping well and woke up frequently, sometimes with nightmares. On mental status examinations in November 2006 and March 2007, mood was anxious and affect was mildly constricted. Speech was normal rate and tone and spontaneous. Sleep was noted to be poor and energy and interests were decreased, but appetite was good. Thoughts were coherent and goal-directed. There were no psychotic, delusional, suicidal, or homicidal thoughts and the Veteran denied suicidal or homicidal plans and he was described as being neither a suicidal nor a homicidal risk. The diagnosis was PTSD. A GAF score of 45 was assigned in November 2006 and a GAF score of 50 was assigned in March 2007. Dr. L.J-M. provided another letter in support of the Veteran's claim in February 2007. She reiterated her opinion that the February 2006 VA examination report documented symptoms of PTSD consistent with a rating in excess of 30 percent. She again reported that the Veteran experienced severe impairments in both social and occupational functioning and stated that his ability to be reliable and productive in his position as a car salesman had been negatively impacted by pain associated with diabetic neuropathy and his ability to be on his feet. She stated that, because the Veteran associated his diabetes with Agent Orange exposure in Vietnam, his experiencing of diabetes symptoms increased his recall of Vietnam and negatively impacted his mood and functioning, especially with increased irritability and easy anger. She reiterated that the Veteran was able to remain employed due to his long work history with his employer and their willingness to accommodate his need to be able to leave work when becoming extremely anxious, irritable, and/or agitated. The Veteran reported that he had to miss work because of medical appointments to address his diabetes and neuropathy and psychiatric appointments to treat PTSD. Because of problems resulting from diabetes, he had had to miss one to two weeks of work a month from June to October 2006. Dr. L.J-M. reported that because of the Veteran's significantly reduced reliability and productivity at work, it was highly improbable that he could secure and maintain another position, as another employer would be unlikely to tolerate the Veteran's excessive absences and that he was unemployable as a result of his PTSD, diabetes, and diabetic neuropathy. She added that, because of his worsening medical condition and the severity of his PTSD, the Veteran experienced severe depression. She stated that February 2007 admission of the BDI placed the Veteran in the severe range of depression and the comparison of these results with previous testing indicated that, despite good compliance with treatment and medication, the Veteran's depression was chronic and resilient and he remained severely depressed. Dr. L.J-M. assigned a current GAF score of 44 and stated that she had referred the Veteran to the Salisbury VA Medical Center (VAMC) for intensive inpatient treatment to address his PTSD because of the chronic severity of that condition. The Veteran again underwent VA PTSD examination in May 2007. He reported that he was short-tempered and was experiencing increased PTSD symptoms. The Veteran stated that he continued to work at the car dealership where he had been for almost 20 years and stated that he missed about two to three days a month from work. He described problems with irritability on the job and trouble dealing with customers. He reported concentration difficulties. The Veteran stated that his employer was flexible, letting him go for a walk and come back when he felt ready, if needed, which was helpful. The Veteran stated that he had a good relationship with his wife. He described his wife as becoming more supportive and understanding as she learned more about his condition, although she had always been fairly supportive, which helped their relationship. The Veteran acknowledged threatening his wife in the past, but stated that he had not done this in 10 years. The Veteran also reported that he was fairly close to his children and grandchildren and saw them fairly often. He denied having close friends, but stated that he was casual friends with some of his co-workers. He denied hobbies, stating that he watched TV when he was home, although he worked a lot and did not have a lot of spare time. The Veteran reported attending church and going out to eat with his wife once a week. On mental status examination the mood appeared to be anxious and affect was congruent with mood. Speech was regular rate and rhythm. Thought process was logical and coherent and thought content was devoid of any current auditory or visual hallucinations, although he reported such symptoms in the context of nightmares. The examiner noted that there was no evidence of delusional content. The Veteran denied suicidal or homicidal ideation. He denied a history of suicide attempts and reported that the last time that he was physically aggressive was five to six years earlier. Memory was intact for immediate, recent, and remote events. He was unable to concentrate well enough to spell "world" backwards and was not able to interpret a proverb. He had fair insight into his current condition. The Axis I diagnoses were PTSD and depressive disorder, not otherwise specified. A GAF score of 53 was assigned. The examiner commented that the Veteran was exhibiting moderate to considerable symptoms associated with PTSD. Specifically, he reported intrusive thoughts of Vietnam on a daily basis and nightmares about Vietnam two to three times a week. He described avoiding talking about the war and watching war movies. The examiner noted that the Veteran described emotional detachment from others and said he isolated and was a bit of a loner with problems trusting people. He reported sleeping three to four hours a night and described an exaggerated startle response to loud noises. He also suggested a hypervigilant style and reported concentration problems. The examiner noted that the Veteran described symptoms of depression with low energy, low motivation, decreased feelings of hope, and decreased interest in activities. The Veteran denied that his symptoms impacted his activities of daily living, such as feeding, bathing, or toileting. The examiner opined that the Veteran's social adaptability and interactions with others as well as his ability to maintain employment and perform job duties in a reliable, flexible, and efficient manner appeared to be moderately to considerably impaired. The Veteran received VA mental health medication management in August 2007. He described his mood as "kind of down in the last few months." He reported that medication was helping with sleep and stated that he slept "pretty well." The Veteran stated that he felt his PTSD symptoms were worsening because of the war in Iraq. He reported avoiding crowds and stated that he was more irritable than usual at work. He stated that he handled his short temper by counting to ten and walking away when he got very angry. He stated that the counseling and group therapy he was receiving via his private psychologist was helpful. He described attending church regularly and reported that he had five children and several grandchildren whom he saw regularly and got along with very well. The Veteran returned for medication management in December 2007. He stated that he was recently becoming increasingly irritable and cranky, especially at work. He reported that he still had nightmares and awoke in a sweat two to three times a week. He described attending church regularly and walking for exercise and mood elevation. He denied suicidal and homicidal ideation. On mental status examination in August and December 2007 speech was spontaneous and normal in rate and tone. The Veteran was cooperative and attentive with euthymic mood and normal range of affect. There were no hallucinations. Thought processes were linear and goal-directed and thought content was appropriate. Suicidal and homicidal ideation were absent and the Veteran was oriented to person, place, time, and situation. Short and long term memory were intact. Concentration, attention, impulse control, insight, and judgment were good. Ability for abstract thinking was intact. He reported varied interests in August 2007 and reported in December 2007 that he engaged in hobbies/interests/work daily. Irritability/anger and depressive/anxiety symptoms were present, as were nightmares. Flashbacks were present in August 2007 but absent in December 2007. A suicide risk assessment from December 2007 reflects that the Veteran denied suicidal thoughts. Protective factors listed included good family/friend relationships and a history of coping with stress adequately. The Veteran reported that he was supported by his wife, children, friends, and church. A January 2008 PTSD evaluation note reflects that the Veteran was being referred to the Salisbury VAMC for possible admission by his private psychologist. Dr. L.J-M. had reportedly noted significant improvement in the Veteran during outpatient treatment, but believed he was in need of inpatient treatment to optimize his recovery process. The Veteran's mood was normal and his speech was clear, distinct, and logically oriented. There was no evidence of a psychotic disorder in his thoughts or behaviors. General memory and intellectual functions seemed to be intact and he denied current suicidal or homicidal ideation. The Veteran reported that he had generally been successful in his work as a car salesman, but was finding it increasingly difficult to maintain his temper at work. During VA PTSD examination in February 2008, the Veteran reported sleep impairment, acknowledging improvement with medication but stating that he still woke up two to four times per night. He also described himself as moody, agitated, and lacking patience. He stated that he had nightmares two to four times a week, from which he woke up anxious and frequently sweating. He reported mild flashback symptoms, stating that he sometimes heard his name called, and described intrusive thoughts almost every day. The Veteran stated that he did not like to go into crowds because he got irritated and had hypervigilance. He reported choosing a seat where he could see the entire restaurant and had easy access to exits when eating in a restaurant. He reported difficulty with anger control, periods of anxiety, and startle to noise. He stated that he avoided programs about war because they brought back vivid memories. The Veteran described his relationship with his wife as "having 'ups and downs'" which he related to his anger. He stated that his wife was very supportive despite this behavior. He reported difficulty in his work as a car salesman because of anger and difficulty interacting with customers. Although his performance had dropped, he stated that his supervisor was quite supportive. The Veteran reported that he was working full-time but took off four to five days or more per month, some of which was because of his PTSD, although he also took time off for his other medical conditions. The Veteran indicated that he was capable of performing his activities of daily living and did so routinely and independently. On mental status examination the Veteran was alert and oriented. Insight was adequate. Affect was mildly blunted. He demonstrated adequate attention and was not distractible. Spontaneous speech was fluent, grammatic, and free of paraphasias. Immediate, recent, and remote memory were all within normal limits. The Veteran was noted to be logical and goal-directed. He reported dysphoria but did not report other symptoms of depression. He denied suicidal or homicidal ideation or plan. There was no evidence of disorder in thought process or content. There was no pressured speech, grandiosity, irritability, or restlessness noted. The Axis I diagnosis was PTSD, chronic. The examiner assigned a GAF score of 50. The examiner commented that the Veteran's presentation was highly consistent with that noted by the other examiners, including his treating psychologist. The examiner noted that the Veteran's treating psychologist indicated that he was totally disabled; however, this was not consistent with the fact that he was still working. Still, the VA examiner noted that the Veteran was having difficulty working and was experiencing a moderate degree of impairment in occupational functioning. He also indicated that the Veteran had a moderate degree of impairment in social functioning as a result of his PTSD. He concluded by stating that the overall level of the Veteran's disability was moderate. During VA treatment in March 2008, the Veteran stated he was doing "very well." On mental status examination, there were no abnormalities of behavior or psychomotor activity. Speech was spontaneous and normal rate and tone. The Veteran was attentive and cooperative and mood was euthymic. Affect was normal ranged. There were no hallucinations. Thought process was linear and goal directed and thought content was appropriate. Suicidal and homicidal ideation were absent. The Veteran was oriented to person, place, time, and situation. Short and long term memory were intact. Concentration, attention, impulse control, insight, and judgment were good. Ability for abstract thinking was intact. The Veteran reported restorative sleep, adequate energy and appetite, and varied interests. Irritability/anger and depressive/anxiety symptoms were described as absent, although the Veteran reported nightmares and flashbacks. Collectively, the evidence during the period from the effective date of the grant of service connection to March 20, 2008 reflects that the Veteran's PTSD has been manifested by intrusive thoughts, flashbacks, nightmares and sleep impairment, irritability and anger, hypervigilance, and emotional detachment from others. Mood was described as dysphoric, depressed, anxious, and sad. Affect was described as constricted, blunted, and flat and the Veteran reported difficulty with motivation. The Veteran described himself as reclusive in January 2006 and reported in February and April 2006 that he was isolating. These symptoms are reflective of occupational and social impairment with reduced reliability and productivity, consistent with a 50 percent rating. Dr. L.J-M. stated in January 2006 that the Veteran experienced significant occupational impairment as a result of PTSD. While the February 2006 VA examiner commented that the Veteran was experiencing a mild level of impairment in social and occupational functioning, the Veteran described limited recreational activities and social supports during this examination. In August 2006, Dr. L.J-M. addressed the Veteran's description of his occupational functioning as made to the February 2006 VA examiner, including his report of fluctuating levels of work performance with an ability to leave work whenever he became extremely irritated, and opined that this was consistent with reduced reliability and productivity. Dr. L.J-M. opined that the Veteran experienced serious impairments in both social and occupational functioning. In February 2007, Dr. L.J-M. reported that the Veteran experienced severe impairments in both social and occupational functioning and referred the Veteran for inpatient PTSD treatment because of the severity of his condition. The May 2007 VA examiner described the Veteran's PTSD symptoms as moderate to considerable. The February 2008 VA examiner noted that the Veteran was having difficulty working and was experiencing a moderate degree of impairment in occupational and social functioning as a result of his PTSD. During VA treatment in June 2006, the Veteran stated that his depression had improved and reported that his symptoms of depression had decreased to the point that he was more effective in most aspects of his life and was more active and involved. However, by August 2006, he reported that his depression was still causing him difficulty in his personal life and at work. For example, he described an inability to focus on his work and irritability; reported that he was very negative and very unhappy; and stated he was having difficulty in interactions with his wife. Resolving any reasonable doubt in favor of the Veteran, the Board finds that an initial 50 percent rating is warranted for the entire period from the effective date of the grant of service connection to March 20, 2008. However, at no point during this period has the Veteran's overall PTSD symptomatology met the criteria for a rating in excess of 50 percent. The evidence does not demonstrate deficiencies in the areas of family relations, judgment, or thinking. Rather, the Veteran described a good relationship with his wife and reported being close with and frequently seeing his children and grandchildren during VA examination in May 2007. While he denied having close friends, he did report that he was casual friends with some of his co-workers and indicated that he attended church and went out to eat with his wife once a week. During this period, judgment was described as well-developed and good and thoughts were described as clear, coherent, and goal directed. The Veteran consistently denied suicidal ideation and there is simply no evidence of obsessional rituals, near-continuous panic or depression affecting ability to function independently, appropriately and effectively, spatial disorientation, or neglect of personal appearance and hygiene. The Veteran described during the February 2006 VA examination an incident in which he flew into a rage and was going to kill his wife, her sister, and his brother-in-law; however, he reported that this incident had occurred six months earlier and, afterwards, he got rid of all his weapons and began seeking treatment. While the Veteran also did report some instances of homicidal ideation in discussing his previous psychiatric history during that VA examination, he denied that he had ever tried to harm anyone. There is no indication of homicidal ideation or plan since the effective date of the grant of service connection, nor does the evidence otherwise suggest that the Veteran is in persistent danger of hurting himself or others or has exhibited grossly inappropriate behavior during this time. Further, despite his reports of irritability and Dr. L.J-M.'s January 2006 reference to outbursts of anger, the evidence during the period in question does not show impaired impulse control as contemplated in the criteria for a 70 percent rating. Dr. L.J-M. opined in August 2006 that the Veteran's fluctuating levels of work performance with an ability to leave work whenever he became extremely irritated, as reported during the February 2006 VA examination, was consistent with difficulty in adapting to stressful circumstances. However, the overall disability picture of the Veteran's PTSD during this period does not meet or approximate occupational and social impairment with deficiencies in most areas, as contemplated in the assignment of a 70 percent rating. With the exception of a GAF score of 53 assigned on VA examination in May 2007, the remainder of the GAF scores assigned during this period ranged from 42 to 50. However, such scores do not provide a basis for assignment of a rating in excess of 50 percent. While, according to DSM-IV, 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), as stated, the Veteran has consistently denied suicidal ideation and there is no evidence of obsessional rituals. Further, the Veteran remained employed during this period and has described having casual friends and regularly attending church. Importantly, a GAF score is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). As discussed, the evidence reflects that the Veteran's overall disability picture most closely approximates a 50 percent rating during this period. Since May 1, 2008 On March 20, 2008, the Veteran was admitted to an inpatient PTSD program at the Salisbury VA Medical Center (VAMC), where he remained until May 1, 2008. The discharge summary from this hospitalization reflects that, on mental status examination, the Veteran was cooperative but appeared aloof and guarded. He was appropriately dressed with good hygiene. The Veteran described himself as a loner who liked to stay within his perimeter with very little social life outside of his immediate family. Mood was euthymic with constricted and mildly tense affect. He had no complaints of significant depression and felt his medications helped him deal with his PTSD. He denied suicidal or homicidal ideas or plans. He was not psychotic and was described as in good control of himself and in good contact with reality. He reported insomnia due to frequent nightmares of war which woke him up startled and sweaty. The Veteran was oriented in all spheres and memory, recall attention (when not distracted with intrusive war thoughts), insight, and judgment were intact. No cognitive dysfunction was exhibited. The Veteran reported re-experiencing his in-service trauma, including through intrusive thoughts and nightmares; avoiding stimuli associated with the trauma, including a feeling of detachment or estrangement from others; and persistent symptoms of increased arousal, including sometimes having irritability or outbursts of anger and having difficulty concentrating when thinking of war or experiencing intrusive thoughts. The summary of the Veteran's hospital course notes that he participated in social, recreational, and exercise activities and was able to enjoy these activities and the company of others. The Veteran was described as not employable due to chronic severe PTSD with persistent symptoms and frequent flare-ups having an adverse impact on several of his physical illnesses. A GAF score of 35 was assigned. In May 2008, Dr. L.J-M. wrote that she agreed with the assessment made by the physicians at the Salisbury VAMC, that the Veteran was not employable because of the chronic severity of his PTSD and the negative impact of that condition on his medical problems. VA treatment records from May 2008 to June 2012 reflect ongoing treatment for PTSD. A June 2008 mental health note reflects that the Veteran felt he benefited greatly from his inpatient PTSD treatment. He denied depressed or anxious moods. In September 2008, the Veteran stated that he was doing "ok" and, while he occasionally had problems sleeping, medication helped. A January 2009 record reflects that the Veteran had recently attended a reunion at the Salisbury VAMC and enjoyed seeing the other attendees. He reported getting along well with his wife and stated that they exercised together every day. On mental status examination in June and September 2008 and January 2009, the Veteran was well groomed and calm and there were no abnormalities in behavior or psychomotor activity. Speech was normal rate and tone. Mood was euthymic. Affect was described as bright in June 2008, normal ranged in September 2008, and congruent to content in January 2009. There were no hallucinations. Thought processes were linear and goal directed and thought content was appropriate. Suicidal and homicidal ideation were absent in June 2008 and January 2009 and were not addressed in September 2008. The Veteran was oriented to person, place, time, and situation. Short and long term memory were intact. Concentration, attention, impulse control, insight, and judgment were good. Ability for abstract thinking was intact. The Veteran reported restorative sleep, adequate appetite and energy, and varied interests. He reported nightmares and flashbacks, but irritability/anger and depressive/anxiety symptoms were absent. A GAF score of 70 was assigned in June 2008. GAF scores of 65 were assigned in September 2008 and January 2009. A January 2009 mental health treatment plan notes that the Veteran's strengths included his impulse control, judgment, social skills, community support, insight, communication skills, and capacity for stable relationships. In May 2009, the Veteran stated that he was sleeping well with only occasional nightmares. He reported that he and his wife were getting along well, and he had recently enjoyed seeing friends at a Memorial Day service he attended. In September 2009, the Veteran reported having both birthday and anniversary celebrations the previous weekend, which he enjoyed. He stated that his children threw a party for his birthday and he took his wife out to dinner for their anniversary. During mental health treatment in November 2009, the Veteran reported that he had been "doing well." He described attending Veterans Day services. He stated that he received much support from his attendance at group and individual therapy with his private psychologist. He indicated that he was looking forward to having Thanksgiving dinner with his family. A March 2010 mental health record reflects that the Veteran continued with group therapy with his private psychologist and noted that he had formed strong bonds with veterans in those groups. He also reported spending time with his grandchildren almost every day and described them as a "source of joy" for he and his wife. He stated that he was getting along well with his wife. The Veteran described his mood as good and reported that he was sleeping well with medication. On mental status examinations in May, September, and November 2009 and March 2010, the Veteran was well groomed and there were no abnormalities in behavior or psychomotor activity. Speech was spontaneous and normal rate and tone. The Veteran was attentive and cooperative and mood was euthymic. Affect was normal ranged and there were no hallucinations. Thought processes were linear and goal directed and thought content was appropriate. Suicidal and homicidal ideation were absent. The Veteran was oriented to person, place, time, and situation. Short and long term memory were intact. Concentration, attention, impulse control, insight, and judgment were good. Ability for abstract thinking was intact. The Veteran reported restorative sleep, adequate appetite and energy, and varied interests. He reported flashbacks in September 2009, but indicated that flashbacks were absent in May and November 2009 and March 2010. He reported improved irritability and anger in September 2009, and described these symptoms as absent in May and November 2009 and March 2010. He reported nightmares in September and November 2009, but described nightmares as absent in May 2009 and March 2010. A GAF score of 65 was assigned in May and September 2009 and March 2010. The Veteran most recently had a VA examination to evaluate his PTSD in March 2012. The Axis I diagnosis was chronic, severe PTSD. A current GAF score of 46 was assigned. The examiner indicated by marked box that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood as a result of his PTSD. The VA examiner was asked to indicate by marked box all symptoms applicable to the Veteran's PTSD. She marked that he had anxiety, chronic sleep impairment, impairment of short and long term memory, and difficulty in adapting to stressful circumstances, including work or a worklike setting. She indicated that he had no other symptoms attributable to PTSD. In a May 2012 addendum, the VA examiner opined that it was more likely than not that the Veteran's PTSD prevented him from securing and maintaining substantially gainful employment. Although the evidence during this period indicates that the Veteran was unemployable as a result of his PTSD, the evidence does not reflect total social impairment. Rather, the summary of the Veteran's hospital course notes that he participated in social, recreational, and exercise activities and was able to enjoy these activities and the company of others. Since May 1, 2008, the Veteran attended a reunion, Memorial Day and Veterans Day services, and reported getting along well with his wife and enjoying a birthday party thrown for him by his children. He reported forming strong bonds with veterans in his private therapy group and enjoying seeing his grandchildren almost every day. Significantly, the March 2012 VA examiner indicated that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas (consistent with a 70 percent rating), and did not mark that his PTSD resulted in total occupational and social impairment. Further, the Veteran has consistently been described as well-groomed and oriented. Memory has been intact, speech has been normal, and there have been no abnormalities in behavior. Thought processes have been described as linear and goal directed with thought content noted to be appropriate. The admission assessment from the Veteran's period of hospitalization does reflect that the Veteran reported seeing and hearing things others did not, specifically, deceased family members. However, there were no hallucinations on mental status examinations in June and September 2008, January, May, September, and November 2009, and March 2010. The evidence since May 1, 2008 does not demonstrate persistent delusions or hallucinations. There is also no indication that the Veteran has been in persistent danger of hurting himself or others. Since May 1, 2008, the Veteran's PTSD symptoms do not more nearly approximate total occupational and social impairment as contemplated in the criteria for a 100 percent rating. The conclusion that a 100 percent rating is not warranted is supported by the GAF scores of 65 and 70 included in the VA treatment records during this period. GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. While the most recent VA examination report included a GAF score of 46, indicating serious symptoms or serious impairment in social, occupational, or school functioning, this is consistent with the 70 percent rating currently assigned during this period. The Board has considered that a GAF score of 35 was assigned during the Veteran's inpatient hospitalization from March to May 2008. Scores ranging from 31 to 40 reflect some impairment in reality testing or communications (e.g. speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g. depressed man avoids friends, neglects family, and is unable to work). Id. It is unclear whether this score was assigned at the Veteran's admission to or discharge from the hospital. In any event, as previously discussed, a GAF score is not dispositive of the evaluation issue. The evidence reflects that the Veteran's overall disability picture does not more nearly approximate total occupational and social impairment since May 1, 2008. Both Periods In adjudicating a claim the Board must assess the competence and credibility of the evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences; for example, he is competent to report that he experiences symptoms such as intrusive thoughts, flashbacks, nightmares and sleep impairment, irritability and anger, hypervigilance, and emotional detachment from others. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran is credible in his reports of the symptoms he experiences and his reported symptoms have been considered, along with the medical evidence, in evaluating the appropriate ratings for his service-connected PTSD since the effective date of the grant of service connection. The Veteran's PTSD has not been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321. The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111 (2008); VAOGCPREC 6-96 (Aug. 16, 1996). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. The schedular criteria are adequate to rate the service-connected PTSD. The rating schedule contemplates the described symptomatology of flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and occupational and social impairment. Moreover, the Court has held that the General Rating Formula also contemplates symptoms not explicitly mentioned therein. Mauerhan, supra. Significantly, there is no medical indication or argument that the applicable criteria are inadequate to rate the disability. The symptoms of the Veteran's service-connected PTSD are adequately compensated in the disability ratings assigned and he does not have symptoms associated with PTSD that have been left uncompensated or unaccounted for the by the assignment of the schedular ratings. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board has resolved reasonable doubt the Veteran's favor in determining that an initial 50 percent rating is warranted for PTSD prior to March 20, 2008, but finds that the preponderance of the evidence is against assignment of a rating greater than 70 percent since May 1, 2008. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial 50 percent rating for PTSD, prior to March 20, 2008, is granted, subject to the laws and regulations governing the award of monetary benefits. A rating in excess of 70 percent for PTSD, since May 1, 2008, is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs