Citation Nr: 1334599 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 11-32 972 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to a rating higher than 50 percent for posttraumatic stress disorder (PTSD) with bipolar disorder. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD A. Dean, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1968 to December 1970. This appeal to the Board of Veterans' Appeals (Board/BVA) is from an August 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). FINDINGS OF FACT For the entire increased-rating period under appeal, the Veteran's PTSD with bipolar disorder has not been manifested by symptoms more nearly approximating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. CONCLUSION OF LAW For the entire increased-rating period under appeal, the criteria have not been met for a rating higher than 50 percent for the PTSD with bipolar disorder. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Codes 9411, 9432 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Standard of Review In deciding this claim, the Board has reviewed all of the evidence in the claims file, both the physical claims file and electronic ("Virtual VA") claims file, and has an obligation to provide an adequate statement of reasons or bases supporting this decision. See 38 U.S.C.A. § 7104(d)(1) (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each and every piece of evidence, certainly not in exhaustive detail. See id. The analysis below therefore focuses only on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board addresses its reasons for rejecting evidence favorable to the claimant. The Board must assess the credibility and weight of all relevant evidence, so both the medical and lay evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against a claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). II. The Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), sets forth VA's duties to notify and assist a claimant in substantiating a claim for VA benefits. The VCAA was codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, and the implementing regulations were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative of any information and medical or lay evidence not of record that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In order to satisfy its duty to notify the claimant under the VCAA, the United States Court of Appeals for Veterans Claims (Court/CAVC) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Ideally, VCAA notice should be provided prior to an initial decision on a claim by the RO as the Agency or Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if notice was not provided prior to initially adjudicating a claim, or if provided and it was inadequate or incomplete, the issuance of a fully compliant VCAA notification followed by readjudication of the claim, including in a statement of the case (SOC) or supplemental SOC (SSOC), is sufficient to "cure" the timing defect in the provision of the notice because the intended purpose of the notice is still preserved, not frustrated, since the Veteran is still given meaningful opportunity to participate effectively in the adjudication of his claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In claims for increased ratings for disabilities that already have been determined service connected in years past, the Court has held that in order to satisfy the first notice element in an increased-rating claim, VA must notify the claimant that he needs to provide or request VA to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability at issue. Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 97-103 (2010) (Vasquez-Flores III); Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008) (Vasquez-Flores I), overruled in part sub. nom. Vasquez-Florez/Wilson v. Shinseki, 580 F.3d 1270, 1280-81 (Fed. Cir. 2009) (Vasquez-Flores II). Further, the claimant must be notified that a disability rating will be determined by applying relevant Disability Codes (DCs), which typically provide for a range in severity of a particular disability from 0 percent, i.e., noncompensable, to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. Id. Finally, the notice must provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Id. Except when VCAA notice as to how to substantiate a claim is not provided at all, it is the claimant's burden to show that he was prejudiced by any deficiency in the notice provided. See Vazquez-Flores, 24 Vet. App. at 106-107. And VA is not required to apprise him of alternative DCs or daily-life evidence, only instead provide what amounts to "generic" notice. Here, prior to the August 2010 rating decision at issue, so in the preferred sequence, a March 2010 letter satisfied all notice requirements under the VCAA. It informed the Veteran of how VA generally evaluates service-connected disabilities, provided examples of the types of evidence he could submit in support of his claim, and notified him of his and VA's respective responsibilities in obtaining relevant records and other evidence on his behalf. Accordingly, the duty to notify has been satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores, 24 Vet. App. at 97-103; Quartuccio, 16 Vet. App. 183. VA's duty to assist under the VCAA includes helping the claimant obtain relevant records, including service treatment records (STRs) and other pertinent records, such as concerning evaluation he has received since service from VA and privately, as well as providing an examination or obtaining a medical opinion when necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). To this end, the Veteran's STRs, post-service treatment records, and Social Security Administration (SSA) records have been obtained and associated with the claims file for consideration. He has not identified any outstanding records that he wants VA to obtain or that he believes are relevant to his claim in terms of showing his entitlement to a greater level of compensation. Therefore, the duty to assist him in obtaining pertinent records has been satisfied. See 38 C.F.R. § 3.159(c). The duty to assist also, as mentioned, includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim. See 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. §§ 3.159(c)(4), 3.326(a), 3.327 (2013); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the claimant's disability and such is relevant to the claim, a new VA examination must be conducted. See 38 C.F.R. §3.327(a); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-91 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. Indeed, even when the claimant challenges a VA examination or opinion, the Board may assume the competency of the VA medical examiner, including nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), he or she is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). Here, VA examinations were performed in May 2010 and even more recently in March 2013. The examinations are adequate for rating purposes, as the examiners reviewed the claims file for the history of this disability, examined the Veteran personally, and described his disability in sufficient detail to enable the Board to make a fully informed decision regarding its severity in relation to the applicable rating criteria. D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). There are no apparent inconsistencies or ambiguities in the examination reports, and the claimant has not specifically challenged its adequacy or thoroughness, or the competence of the examiners. See Sickels, 643 F.3d at 1365-66; Rizzo, 580 F.3d at 1290-91. The Veteran has not stated and there is no evidence indicating that there has been a material change in the severity of his PTSD with bipolar disorder since he was last examined in March 2013. See 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the mere passage of time since an otherwise adequate VA examination was performed. Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11-95 (April 7, 1995). Accordingly, VA's duty to assist with respect to obtaining a VA examination has been met. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. at 312. In sum, VA's duty to notify and assist under the VCAA has been satisfied. The Veteran has had ample opportunity to participate effectively in the development of this claim. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . must be considered prejudicial")). Any defect in the notice or assistance provided will not affect the outcome of this claim or compromise the "essential fairness of the adjudication," and no such defect has been shown. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). To the contrary, he has received all essential notice and assistance, has had a meaningful opportunity to participate effectively in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Thus, any error in the notice or assistance provided was harmless, again, meaning nonprejudicial. See Shinseki v. Sanders, 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless, and that it is the burden of the claimant to show the error was harmless by at least providing an explanation as to how the error caused harm); see also 38 U.S.C.A. § 7261(b)(2) and 38 C.F.R. § 20.1102. Accordingly, the Board may proceed with appellate review of this claim. III. Legal Criteria Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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. See 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the Veteran's favor. 38 C.F.R. § 4.3. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Where, as here, entitlement to compensation already has been established, and an increase in the disability ratings is at issue, the present level of disability is the primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); 38 C.F.R. § 4.2. In determining the present level of disability; however, "staged" ratings are appropriate for increased-rating claims when the factual findings show distinct time periods where the service-connected disabilities have exhibited symptoms that would warrant different ratings. The relevant temporal focus for adjudicating increased-rating claim is on the evidence concerning the state of the disability from one year before the claim for higher rating was filed - so, here, since February 2009 - until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007); 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but 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, irrespective of whether the Veteran raised them, as well as the entire history of his disabilities in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Mental disorders, including PTSD and bipolar disorder, are evaluated under the General Rating Formula for Mental Disorders found at 38 C.F.R. § 4.130, Diagnostic Codes 9411, 9432. In addition, the Fourth Edition of the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (DSM-IV) provides guidance for the nomenclature employed in this VA regulation. When evaluating a mental disorder, the evaluation must be based on all the evidence of record bearing on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). A rating of 50 percent under the General Rating Formula for mental disorders is appropriate when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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. 38 C.F.R. § 4.130, DCs 9411, 9432. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In evaluating the evidence, the Board also considers Global Assessment of Functioning (GAF) scores that clinicians have assigned. A GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; instead, the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. The higher the GAF score, the higher the overall functioning of the individual is. For instance, a GAF of 61 to 70 is defined as "some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." A GAF of 51 to 60 is defined as "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)." A GAF of 41 to 50 is defined as "[s]erious 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)." A GAF Scale score of 31 to 40 indicates some impairment in reality testing or communication (e.g.., speech is at times illogical, obscure, or irrelevant), or a major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed person avoids friends, neglects family, and is unable to work). DSM-IV, at 32; Richard, 9 Vet. App. at 267. IV. Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of this service-connected disability. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is inadequate for rating purposes. The Veteran contends that his service-connected PTSD with bipolar disorder is more severe than 50-percent disabling under 38 C.F.R. § 4.130, DCs 9411, 9432. In an April 2010 statement, in support of his claim for a higher rating for this disability, the Veteran reported that he did not like to be around a lot of people and that his temper was worse. He stated he had a lot of stress and anxiety and rarely left the house. He further reported that he saw his psychiatrist more frequently and his therapist once a week. His medication had been increased but he stated it did not help him that much. His wife also provided a statement in April 2010, in which she affirmed that his nightmares, excessive drinking, mood swings, sadness, and depression had been an ongoing problem for the family. She said he had low moods, refused to go to crowded places, and had erratic sleep patterns with nightmares and restlessness. She added that she had to ensure he took his medication, otherwise he would go on spending sprees that caused financial difficulties. The following month, so in May 2010, the Veteran had a VA compensation examination. He reported experiencing depressive episodes that lasted a few weeks and manic episodes that lasted approximately one week. He estimated that it had been a few months since his last manic episode, and that the mania was effectively managed with medications. He reported having a depressed mood most of the day, nearly every day; diminished interest in activities; fatigue and loss of energy; and decreased ability to think or concentrate and indecisiveness; he also reported distinct periods of abnormal and persistent elevated, expansive, or irritable mood; inflated self-esteem or grandiosity; distractibility; and excessive involvement in high-risk pleasurable activities. He indicated he had been married for 30 years and described his relationship with his wife as "good," but noted they were separated from 2000 to 2002. He reported having good relationships with his two adult children, one of whom lived at home because of an addiction that was in the process of being treated. The Veteran said he had "a couple" of good friends. In his spare time he reported restoring an old truck and said he used to play softball but had stopped on account of his knee problems. He stated he did less activities in the past year due to poor sleep and lack of motivation or interest. He denied a history of suicide attempts and violence. He reported that two friends recently had died, and that he was a recovering alcoholic and had been sober for eight years. On objective mental status examination, he was observed to be clean, neatly groomed, and appropriately and casually dressed. His psychomotor activity, speech, thought process, and thought content were unremarkable, and his attitude toward the examiner was cooperative. The examiner described the affect as normal and the mood euthymic. The Veteran's attention was intact; he understood the outcome of his behavior; and his intelligence was average. The examiner noted that the Veteran had a sleep impairment since he reported sleeping four to five hours per night, with nightmares related to his combat experience in Vietnam approximately five to twenty times per month. He did not suffer from delusions, hallucinations, inappropriate behavior, obsessive or ritualistic behavior, panic attacks, homicidal thoughts, or suicidal thoughts. He had good impulse control and was able to maintain minimum personal hygiene, although he noted moderate problems with engaging in exercise and other recreational activities due to lack of interest or ambition. He also reported thoughts about Vietnam every day, but that did not interfere with his functioning, and he denied having flashbacks. He reported avoiding thoughts and conversations about the war, as well as hunting, shooting, war movies, and crowds. He denied feeling disconnected from others, but reported mild feelings of irritability, hypervigilence, and difficulty with concentration. He stated that the severity of the symptoms was about the same the past year. The examiner confirmed the diagnoses of PTSD and bipolar disorder and assigned a GAF score of 55. The examiner noted there was not total occupational and social impairment due to the PTSD with bipolar disorder, nor did the symptoms result in deficiencies in judgment, thinking, family relations, mood, work, or school. The examiner opined that the Veteran had reduced reliability and productivity due to his symptoms, which included a lack of interest in things he used to enjoy, frequent nightmares related to Vietnam combat, problems with sleep, irritability, concentration, hypervigilance, and exaggerated startle response. More recently, in March 2013, the Veteran had another VA compensation examination. He reported no change in his marital status since his last VA examination. He said his son still lived with them, but that he was no longer using drugs. The Veteran reported that he kept in touch with family in New York by telephone. He said he had not worked on restoring his truck in awhile due to depression, and that he mainly stayed at home. He reported going out to dinner with his wife every so often but reiterated he disliked crowds. He reported that he was last employed in 2008 but had retired early due to a knee replacement and mood swings. He stated he was seeing a doctor for medication management, that he recently had completed anger management, and that he had no psychiatric hospitalizations or suicide attempts. He also denied legal problems or aggressive or violent behavior. He reported that, after being sober for ten years, he had started to drink again, consuming a six-pack of beer approximately three times a week. He denied using any illicit drugs. He denied having any manic episodes since 2010. He reported experiencing depressed mood daily for the whole day, as well as anhedonia, decreased energy, feelings of worthlessness, and suicidal ideation. He stated the suicidal ideation had been on and off for the past few weeks, and he thought about shooting himself the day prior to the examination. He stated he did not act on his thoughts because his nephew recently had committed suicide and the Veteran had experienced the devastating impact it had had on the family. He denied current intent to commit suicide and believed he was safe. On objective mental status examination, the examiner observed the Veteran was casually, appropriately dressed and well-groomed. He was socially appropriate and made good eye contact. His speech was fluent and of normal rate, rhythm, and volume. His thought process was linear and goal-oriented. His mood was dysthymic with congruent affect, and he was tearful at times. The examiner confirmed the diagnoses of bipolar disorder and PTSD, and also diagnosed alcohol dependence. She assigned a GAF score of 50. She explained the Veteran had occupational and social impairment with reduced reliability and productivity, and that his PTSD, bipolar disorder, and alcohol dependence were mutually aggravating conditions, so their impact on his functioning could not be separated without resorting to undue speculation. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (When it is not possible to distinguish or differentiate the extent of symptoms or impairment that is attributable to service-connected disability versus conditions not service connected, 38 C.F.R. § 3.102 and 4.3 require that VA resolve this reasonable doubt in the Veteran's favor and, for all intents and purposes, presume the symptoms or impairment in question is attributable to service-connected disability). A review of the Veteran's private treatment records shows that he regularly sees a psychiatrist and therapist, and that he is on medication for his symptoms. He also receives SSA disability benefits for a primary disability of osteoarthritis and a secondary disability of mood disorder. From this record of evidence, for the entire increased-rating period under appeal, the Board finds that the Veteran's PTSD with bipolar disorder has not met or more nearly approximated the criteria for the next higher 70 percent rating under DCs 9411 and 9432. See 38 C.F.R. § 4.130. Indeed, in describing the severity of this service-connected disability, both the May 2010 VA compensation examiner and more recent March 2013 VA compensation examiner indicated this disability causes "...reduced reliability and productivity..." - so referenced the specific language of the General Rating Formula commensurate with a rating at the 50 percent level rather than higher 70 percent level or even greater 100 percent level. Each examiner also cited the specific symptoms supporting this conclusion and, even more importantly, discussed how these particular symptoms affect the Veteran's occupational and social functioning. Neither examiner indicated the Veteran has "...deficiencies in most areas..." so as to warrant a higher 70 percent rating, much less "[t]otal occupational and social impairment..." to warrant an even greater 100 percent rating. And this is true even despite their relatively slight difference in GAF score - 55 during the May 2010 VA compensation examination, which indicates "moderate" social and occupational impairment, versus marginally less, 50, during the more recent March 2013 VA compensation examination, indicative of "serious" social and occupational impairment. More so during the more recent March 2013 VA compensation examination, the Veteran reported experiencing some suicidal ideation, although he also indicated he had no actual intent, owing to the fact that his nephew had committed suicide and the Veteran consequently had seen and experienced the devastating effect this has on the family unit that remains that has to try and deal or cope with this unexpected loss. Suicidal ideation is one of the symptoms listed in the criteria for a higher 70 percent rating under DCs 9411 and 9432. But the same examiners who acknowledged this finding also determined the Veteran does not experience near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, so does not experience some of the other symptoms and impairment characteristic of a rating at this higher level. And although, according to the holding in Mauerhan, it is not necessary the Veteran experience all or even most of the symptoms described for a particular rating, the Board must also reiterate that in assessing the overall level of his occupational and social impairment the VA examiners specifically referenced the language of the 50 percent rating rather than that of the higher 70 and 100 percent ratings. Moreover, they referenced specific symptoms in this assessment, so did not confine their assessment only to matching this symptom with a particular rating versus that symptom with another, instead, provided the required indication of how these symptoms, on the whole, so considered in the aggregate or collectively, affect the Veteran's social and occupational functioning. Further concerning occupational impairment, in particular, the Veteran clarified that the plant where he had worked was shutting down and relocating and he had to have knee replacement surgery, so he in effect decided to retire early. The information obtained from the SSA indicates the primary reason for his disability payments is his osteoarthritis - presumably affecting his knee and for which he had the knee replacement surgery, as opposed to his mood disorder, which is secondary. Moreover, the evidence of record does not indicate other instances of difficulty in adapting to stressful circumstances, including his son moving home because of a drug addiction. Therefore, the evidence of record does not suggest there is inability in adapting to stressful circumstances (including work or a work-like setting). In addition, the May 2010 VA examiner indicated the Veteran's speech was unremarkable. The March 2013 VA examiner expounded on this, indicating the Veteran's speech was fluent and of normal rate, rhythm, and volume, and that his thought process was linear and goal-oriented. It therefore cannot be said that his speech has been intermittently illogical, obscure, or irrelevant, as contemplated in the criteria for the next higher 70 percent rating. Moreover, there is no suggestion his disability has been manifested by obsessional rituals that interfered with his routine activities; spatial disorientation; or neglect of his personal appearance and hygiene, as also contemplated in the criteria for the next higher 70 percent rating. Aside from that, although he noted having just a relatively small social network outside of his family and only a few friends, the evidence of record consistently shows he reported maintaining a stable relationship with his wife and children, other than perhaps during their 2-year separation from 2000 to 2002, and he keeps in touch with other family members who live as far away as in New York. This evidence, on the whole, tends to weigh against a finding of an inability to establish and maintain effective relationships, another requirement for a higher 70 percent rating. Having reviewed the evidence of record for the entire increased-rating period under appeal, the Board acknowledges the Veteran's reported symptomatology was slightly worse during his March 2013 VA examination than previously during his May 2010 VA examination. However, even considering the results of the more recent examination he does not satisfy the criteria for a higher schedular rating of 70 percent for his service-connected PTSD with bipolar disorder, much less for an even greater 100 percent rating. And this is true since one year immediately preceding the filing of this increased-rating claim, so the Board also cannot "stage" this rating. See Hart, 21 Vet. App. at 505 (indicating the relevant temporal focus is from one year before the claim for a higher rating was filed until VA makes a final decision on the claim). See also 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). And since, for the reasons and bases discussed, the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is inapplicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert, 1 Vet. App. 49 (1990). V. Extra-Schedular Consideration The Board also has considered whether the Veteran's claim should be referred for an extra-schedular rating. See 38 C.F.R. § 3.321(b) (2013); Thun v. Peake, 22 Vet. App. 111, 114 (2008). The Board finds that referral for extraschedular consideration is unwarranted. As discussed, the Veteran's service-connected PTSD with bipolar disorder is contemplated and reasonably described by the regular schedular rating criteria, which account both for various types of symptoms and their effects on occupational and social functioning. See id. He does not have symptoms associated with this disability that have been left uncompensated or unaccounted for by his schedular rating. See Thun, 22 Vet. App. at 115. Accordingly, the Board finds there is not the required suggestion that his service-connected psychiatric disorders present "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Consequently, the Board finds that the available schedular evaluation is adequate to rate this disability. As such, in the absence of this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). ORDER The claim of entitlement to a rating higher than 50 percent for the PTSD with bipolar disorder is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs