Citation Nr: 1334946 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 10-01 279 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma THE ISSUE Entitlement to an initial evaluation for post traumatic stress disorder (PTSD) in excess of 30 percent from January 10, 2006 to January 5, 2010, and in excess of 50 percent from January 6, 2010 to October 6, 2011. REPRESENTATION Appellant represented by: James G. Fausone, Attorney ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from February 1993 to March 1995. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a May 2008 decision by the RO which granted service connection for PTSD and assigned a 30 percent evaluation; effective from January 10, 2006, the date of receipt of claim. The Board remanded the appeal for additional development in June 2011. By rating action in October 2011, the RO assigned an increased rating to 50 percent from January 6, 2010, and to 70 percent from October 7, 2011. In October 2011, the Veteran's attorney advised VA that the Veteran was satisfied with the 70 percent rating from October 7, 2011, but disagreed with the 30 and 50 percent ratings assigned for the relevant periods. In August 2012, the Board denied increased ratings in excess of 30 percent prior to January 6, 2010, and in excess of 50 percent prior to October 7, 2011, and the Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a June 2013 joint motion for remand (JMR), the Court vacated the August 2012 Board decision, and remanded the matter for compliance with the terms of the JMR. FINDINGS OF FACT 1. Prior to January 6, 2010, the Veteran's PTSD was manifested primarily by irritability, anger, depressed mood and anxiety but was not productive of occupational and social impairment with reduced reliability and productivity. 2. From January 6, 2010 to October 6, 2011, the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity due to various symptoms contemplated by a 50 percent schedular rating, and no higher. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation for PTSD in excess of 30 percent prior to January 6, 2010, are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.126, 4.130, Part 4, Diagnostic Code 9411 (2013). 2. The criteria for an evaluation for PTSD in excess of 50 percent from January 6, 2010 to October 6, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.126, 4.130, Part 4, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before addressing the merits of the Veteran's claim, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). The notification obligation in this case was accomplished by way of letters from the RO to the Veteran dated in February and March 2006. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); see also, Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Furthermore, the Veteran is challenging the initial rating assigned following the grant of service connection. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). As to VA's duty to assist, the Board finds that all necessary development has been accomplished and that appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service treatment records (STRs) and VA medical records have been obtained and associated with the claims file. The Veteran was examined by VA during the pendency of this appeal and was afforded an opportunity for a personal hearing, but declined. The Board has also reviewed the Veteran's Virtual VA records. Further, neither the Veteran nor her attorney have made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the issue on appeal, and have not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced her in the adjudication of her appeal. See Shinseki v. Sanders, 129 S.Ct.1696 (2009). Based on a review of the claims file, the Board concludes that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Increased Ratings - In General In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, as in the present case, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Under Diagnostic Code (DC) 9411, a 30 percent evaluation is assignment 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 30 percent rating is awarded. A 50 percent evaluation is assigned when PTSD results in occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo-typed 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 disability evaluation is contemplated for 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when there is evidence of total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). The use of the term "such as" in the general rating formula for mental disorders 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 symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as" followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-IV. See 38 C.F.R. § 4,125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). Factual Background The Veteran's attorney asserted that the Veteran's self reported PTSD symptoms are much more serious than assessed by the VA examiners and that she has serious relationship issues at home, frequent panic attacks, memory issues, mood disturbances and impairment in judgment and abstract thinking, and should be assigned a rating of 50 percent or higher from the initial grant of service connection. (See December 2010 VA Form 9). The attorney also argued that the Veteran's multiple marriages and conflicts with her mother, sister and daughter shows that she has difficulty establishing and maintaining effective social and familiar relationships, and that her alcohol abuse was indicative of impaired impulse control which would warrant a 70 percent evaluation under the rating criteria for PTSD. Following a review of the evidence of record, the Board finds that a 30 percent evaluation is warranted for the Veteran's PTSD from the date of her claim to January 5, 2010, and a 50 percent schedular rating from January 6, 2010 to October 6, 2011. In reaching this decision, the Board has considered all the evidence of record, including the numerous VA outpatient notes and the assigned Global Assessment of Function (GAF) scale scores during the relevant periods of this appeal. In order to address the attorney's contentions and to assess the severity of the Veteran's PTSD symptoms, the Board finds that a discussion of the Veteran's history as described in the service records and numerous VA psychiatric treatment reports of record would be beneficial to understanding the progression and severity of her current psychiatric problems. The evidence shows that the Veteran was first married at age 17, while in high school and divorced in August 1993, at age 19, shortly after entering military service. She married her second husband in December 1993, and had her first child in May 1994. (See Veteran's Declaration of Status of Dependents, dated in June 2000). The STRs showed that the Veteran had weight problems in service and was counseled about it on several occasions beginning in October 1994. The records showed that she was put on a weight reduction program that included PT testing every two weeks, but exhibited little to no effort to pass the PT tests or to lose weight and had actually gained weight during the program. During a counseling session in January 1995, the Veteran stated that she no longer wanted to remain on active duty, and was subsequently discharged from service in March 1995. At the time of discharge from service, the Veteran specifically denied any history of frequent trouble sleeping, depression or excessive worry, loss of memory or nervous trouble of any sort, and no pertinent psychiatric abnormalities were noted on examination. Subsequent to service, the Veteran had a number of gynecological problems due to human papilloma virus (HPV) infection that she reportedly got from her second husband during service (see January 2002 VA outpatient note), and underwent a transvaginal hysterectomy at a VA facility in November 2000. (Service connection has been established for residuals of the hysterectomy.) A January 2002 VA outpatient note showed that the Veteran was referred to the substance abuse clinic for marijuana use, at which time she reported that she started smoking marijuana in 1995 to calm herself from panic and anxiety attacks. She reported that she was discharged from service after she failed a PT test, which she believed was in reprisal to a sexual harassment complaint she filed against a supervisor. The records showed that the Veteran was first seen by VA psychiatric services in October 2005, at which time she reported a lengthy history of physical and emotional abuse dating back to childhood. She said that she was a people-pleaser and basically found herself in relationships to fix others or to please them. Her mother was a chronic alcohol abuser for most of the Veteran's life, and she said that she was trying to keep her mother clean and sober. The Veteran reported that she has been struggling with her own sobriety for several years and had stopped using methamphetamines four to five years earlier. During service, she wanted to please people and to make herself indispensible, but she indicated that it was not a supportive environment. She said she was sexually harassed in service and was eventually discharged to cover up her superiors mishandling of her harassment complaint. On mental status examination, the Veteran was alert and well oriented, her affect was appropriate and mood congruent, and her thought processes were logical and goal-oriented. The Veteran's thought content was focused on her history of childhood abuse and military sexual harassment as well as a rape that occurred in 2005. The examiner commented that the Veteran's anger was a manifestation of her depression and noted that her interpersonal functioning was poor. The Veteran had been married five times and made demeaning statements about her current (5th) husband, which the examiner indicated was her way of avoiding work on herself, and that she was focused on her claim and not working on the underlying issue of, in her words, being a "door mat for others." The Veteran was referred to the Women's Mental Health Group (WMHG) for individual counseling for depression management and coping skills. A VA WMHG note in December 2005, indicated that the Veteran shared her growth, including setting boundaries with her mother and gaining some insight into how she uses relationships to fill the void of need for her mother. The psychologist indicated that the Veteran's group contribution was appropriate and that her mental status was unremarkable. The assessment included panic disorder and relational problems. When seen by VA in February 2006, the Veteran reported that the medication (Divalproex) helped and that she was less impulsive and more relaxed. She said that she was still in the process of a divorce and was in no hurry to get involved in another relationship, and that she had her female friends which was a help. On mental status examination, the Veteran was well oriented, her speech was of normal rate, rhythm and tone, and her eye contact and mood were good. Her affect was non-restricted, nonlabile and appropriate, and her memory was grossly intact. Her thought processes were logical and goal-directed, and there were no suicidal or homicidal ideations, hallucinations or delusions. Her kinetics were normal and her insight and judgment was good. When seen in July 2006, the Veteran was concerned about her recent weight gain of 20 pounds since starting on Divalproex, but said that the medication was helping her mood. The examiner noted that she was a very self-conscious individual especially about her appearance and did not like her weight gain. The Veteran's medication was changed to Topiramate - which the examiner indicated was a good alternative and would help with her weight loss. The mental status findings were the same as reported on the February 2006 note. VA outpatient records in August 2006, showed that the Veteran was treated for infections of recent tattoos on her arms, legs and ankles. When seen by VA psychiatric services in August 2006, the Veteran reported that she was feeling better about herself on the new medication and had lost weight, but was feeling somewhat agitated because it was the first day of school and she needed to get her son to school. When seen by VA psychiatric services in September 2007, the Veteran reported that she was stable on her current medications and that her mood was ok and her sleep was average. She reported some irritability and occasional anger outbursts, and was upset that her claim with VA had been denied. She said that she usually takes good care of her children, but had less desire to interact. The Veteran reported that she was forced to retire from the Army following sexual harassment, and that she had anxiety problems, sleep disturbance and worried about her body image. She felt embarrassed for being sexually harassed and weak and angry that nothing was done to stop the harassment. She had anxiety related with her PT testing and thought that the evaluator would fail her. She said that she filed a complaint against that person and was outraged that no action was taken on her complaint. After her discharge from service, she went through a period of depression, anxiety, frustration, had problems with relationships, got divorced, and did not feel safe trusting anyone. She had difficulty with sleep, started gaining weight, had nightmares and flashbacks of her harassment when she worked as a private contractor for the military, and finally sought psychiatric help in 2005. She reported a history of childhood neglect and an absent father most of her life. She was emotionally disconnected from her mother and had anger and resentment toward her. She denied any current use of alcohol or illicit drugs. The mental status findings noted that she was tearful with an angry and anxious mood. The remainder of the mental status findings was unchanged from the previous reports in February and August 2006. The diagnoses included PTSD and bipolar disorder, and the Global Assessment of Functioning (GAF) score was 60. The report noted that the Veteran was advised about the importance of taking her medications as prescribed, of the dangers of changing dosages without consulting with providers, and of the side effects of consuming alcohol with the medications, including cognitive impairment. The Veteran acknowledged her understanding of the risks. When seen in November 2007, the Veteran reported that she was doing a little better on her medications and was involved in a new relationship, but would like to take some time before making any decisions. She said her medications were working but that she still gets irritable and angry and had issues with her mother. She was a little tearful when mentioning how difficult it was for her to trust other people. The examiner indicated that there was no evidence of manic symptoms or recent manic episodes, and that her alcohol use was occasional. There was no change in the mental status findings, and the Veteran's memory was grossly intact. When seen by VA in April 2008, the Veteran reported that she was doing well and had more good days than bad, and that the current combination of medications was working well. She had come up with new goals for her health and was working out and trying to quit smoking. She still gets anxious around a lot of people and was not able to function in public places, but had been in a good mood, had a good appetite and was sleeping well. She continued to have relationship conflict with her mother and accepted that it might not improve unless her mother was prepared to deal with it. There were no psychotic or manic symptoms, her memory was grossly intact and the mental status findings were unchanged. There was no change in the reported mental status findings on VA treatment notes in July and August 2008. When seen by VA in September 2008, the Veteran reported that she was concerned about getting depressed in the coming winter because it happens almost ever year. She had a good summer and was able to socialize with her friends, but had a disagreement with one friend and was not talking to her. She reported that she had not been going to her WMHG meetings because of a disagreement with the counselor. The examiner indicated that there was no evidence of manic, depressive or psychotic symptoms. The Veteran reported that she was not getting out of the house that much. The Veteran's memory was grossly intact and there were no changes in the mental status findings on examination. The GAF score was 65. When seen by VA in November 2008, the Veteran expressed anger about the women's group, but said that she was doing well and was getting rid of the negative people in her life. She continued to struggle with her relationship with her mother and sister, and was going to try and cut them off. She also reported that her cousin died and that she thought it was murder. There was no change in the mental status findings. When seen later in November 2008, the Veteran reported that she was having a difficult time and was feeling depressed. She said that she had been drinking but recently cut down on her consumption. The Veteran reported that she had some unresolved issues with her deceased cousin, and that her daughter had moved out of the house to live with her father. She said that it was difficult for her, but that she had some support from her friends. The Veteran denied any manic symptoms, her memory was grossly intact and there was no change in the mental status findings. The Veteran was counseled about the risks of taking high doses of Wellbutrin when drinking and reported that she had read the risks on the WEBMD and understood them, but wanted to continue taking the medication. The diagnoses included PTSD, bipolar disorder and possible alcohol abuse. The GAF score was 55. When seen by VA in March 2009, the Veteran reported that she was doing well and was engaged. She reported that she was no longer drinking heavy and felt like the Naltrexone was working well. She said her mood was stable on the medication and that she had no recent nightmares, but still had some difficulty around other men. She reported occasional alcohol use, and said that she continues to struggle with her relationship with her mother. There was no change in the mental status findings, and the GAF score was 60. When seen by VA in April 2009, the Veteran reported that things were getting better after a major family event. She reported that her daughter was recently diagnosed with bipolar disorder and that her son was now in therapy as well. She reported that she cut ties with her mother due to multiple betrayals and was working on setting limits and boundaries with her family. She was also very excited about her upcoming marriage later in the month and felt that her life was settling down. She also reported that she wanted to resume attending the women's group sessions. There was no change in the mental status findings, and the risk assessment was minimal. VA group session therapy notes from July to October 2009, showed that the Veteran interacted spontaneously in group discussions, identified positive aspects of herself, identified coping skills, and was taking action to reduce life stressors. The mental status findings were unchanged. A treatment note, dated in October 2009, indicated that the Veteran was tearful when talking about her weeks stress and reported that her mother had been in and out of the hospital. The Veteran said that she decided to forgive her mother and let go of her anger, but that her mother's abusive behaviors were continuing. The Veteran reported mixed emotions because it appeared that her mother may be dying. A VA social worker noted in November 2009, showed that the Veteran was in crisis because her appointments kept getting canceled and pushed up without her being informed. She said that her neurologist told her to increase her Topiramate medication for her migraines, then threatened to put her in the hospital and detox her off all medications. The Veteran reported that she was doing well on Welbutrin and her other psychiatric medications but was having increased anxiety, forgetfulness and problems with relationships since her dosage of Tropromax was increased. The assessment noted that the Veteran was clearly in crises and was offered support, but that her complaints were all due to a medication issue or appointments being changed. When seen by VA psychiatric services in January 2010, the Veteran reported that she was very upset with the clinic and complained that her needs were not being met. She said that she wanted to change providers, but later changed her mind. She reported that her PTSD symptoms were getting worse, but did not want her medications changed because they were helping her and wanted to see a psychologist for individual therapy. She admitted to drinking three to four glasses of alcohol every other night, and said that she had marital problems and anger toward her husband because he was not helping her out. On examination, the Veteran's memory was grossly intact and the mental status findings were unchanged. The GAF score was 55. The Veteran was told by the examiner not to drink alcohol while taking her medications and said that she understood the risks and was willing to quit drinking. On a screen for alcohol use, the Veteran reported that she consumed two to four alcoholic beverages per month during the past year, and had one to two drinks on a typical day. On a PTSD screen, the Veteran responded in the affirmative to nightmares or thoughts about her PTSD stressor when she did not want to, went out of her way to avoid thinking about her stressor and was constantly on guard, watchful or easily startled, but denied that she felt detached from others, activities or her surroundings. When seen by VA psychological services in April 2010, the Veteran reported that she stopped attending the women's support group because she did not think it was helpful to her because it was not specific for sexual trauma, and that she was upset with the group therapist and her psychiatrist. She reported severe panic attacks, high levels of anxiety, flashbacks, intrusive images, hypervigilance, exaggerated startled response, difficulty with loving feelings toward others, decreased need for sleep, talking faster than usual, racing thoughts and distractibility for the past week and a half. She reported that she had an extra-marital affair in February and did not feel like her medication was working. She recently separated from her husband after he punched her and was in the process of filing for divorce. She also reported that her daughter was not doing well with her bipolar disorder. The Veteran reported that she drank two beers the day before despite taking Naltrexone, and said that she used marijuana every four months. On mental status examination, the Veteran was well oriented casually dressed and neatly groomed. She was polite and cooperative and maintained good eye contact throughout the interview. Her speech rate and quality was within normal limits and not pressured, and the content was appropriate to the conversation with no evidence of loose associations. Her thought processes were goal directed, linier and logical and her affect was mood congruent, non-restricted and within normal limits. Her mood was angry, depressed and anxious. The diagnoses included PTSD and bipolar disorder, and the GAF score was 50. When seen later in April 2010, the Veteran reported that she takes her medications regularly, but had worsening anxiety and wanted help immediately. The examiner offered to adjust her medications, but the Veteran reported that she did not want them changed and believed that they were helping her, but that she just needed more counseling. The Veteran reported that her hypomanic symptoms had stopped but that she was feeling stressed and had difficulties with her memory. She reported sadness about her divorce and of her relationship with her daughter, saying that her daughter was breaking many rules lately. The Veteran was counseled to stop her alcohol use as it could have a significant and potentially lethal interaction, and said that she understood the risks and was willing to quit drinking. The GAF score was 55. When seen in May 2010, the Veteran reported that she suffered from verbal, physical and emotional abuse as a child and that there was a lot of conflict in the house. She said that she had trouble making friends, but had one or two close friends. She reported that she participated in spur of the moment activities, hangs out with a crowd at a local bar or restaurant a little bit, and that she worked on hobbies a lot. She reported that her mother was an alcoholic and that there was a lot of neglect and some physical abuse in her childhood. When asked about her alcohol consumption, the Veteran reported that she stopped drinking because alcoholism runs in her family. She said that she didn't know the risks of drinking while taking her medications and so she stopped. She said she was drinking a couple of beers a day every other day or so, and that she used to smoke marijuana. She said that her last drink was the previous weekend, and that she last smoked marijuana two weeks earlier - prior to that it was five or six months. When seen in June 2010, the Veteran reported that her stressors were improving and that she got her home back and was planning to move back in next week with her kids. She felt that her mood was stable most of the time but was still having sleep problems and anticipating anxiety attacks. She denied any active depressed mood and reported that she stopped drinking, but said that she may have had a drink or two over the weekend. She said that the Naltrexone helped her a lot to stop drinking. The Veteran's memory was grossly intact and her mental status findings were unchanged. In July 2010, the Veteran was seen by a new VA psychiatric therapist for counseling and treatment. The Veteran reported that she had one glass of wine the previous night, but had no desire to binge or get drunk. She said she was compliant with Naltrexone and that it was helping her to stop drinking. She said her mood was stable and that she felt empowered by her current level of functioning. She had no interest in a new relationship and was doing things on her own, whereas in the past she would have asked for her husband's help. The Veteran reported a strained relationship with her mother and siblings but described a positive support system of female friends. She talked about her experiences with men and her desire to find someone who will not disappoint her. She identified and discussed what characteristics attracted her to each man and processed what each marriage had in common. She said that she needed someone who was "stronger than she is" and was tired with being the "man" in the relationship and having to control what happens. She said that she spent a lot of time ruminating about her military experiences and regretted that she wasn't given the opportunity to make the military a career. The Veteran reported that she wanted to focus on her children and described feeling guilty about their issues as both children were involved in mental health treatment. On mental status examination, the Veteran was casually dressed and groomed. She was tearful throughout the session, her thought processes were clear and coherent and her insight and judgment was intact. When seen a week later, the Veteran described the emotional challenge of having a relationship with her mother, and said that she called recently asking for urgent help but that the Veteran considered the circumstances and decided her mom's situation could wait. She said that this was a pattern for her mother and felt that she was enabling her and her alcoholism if she rescued her immediately. She described her "care-taking" role for her mother and younger sister most of her life and said that this was a pattern she continued with her current relationships, particularly with men. She talked about her current husband and promoting his artistic talents, and discussed her personal talents and her ability to promote herself and her recent efforts to increase her independence (i.e., writing her memoirs and starting an online hair accessory company). She described her disappointment in the men she had chosen because they failed to fulfill the fatherly role she expected for her son. When seen a few days later in July 2010, the Veteran reported that her mother passed away and that she expressed sadness and regret that she did not get closure. When seen in August 2010, the Veteran was tearful when discussing her mother's death and was stressed over her loss. She reported that things were improving in her life and felt that individual counseling was more suitable for her. She reported that she had a drink after her mother died, but nothing in the last five days. When seen in mid-August 2010, the Veteran reported that she felt that the issues surrounding her mother's death had settled down and said that her response to stress usually involved "decompensating" but that she felt more in control. The Veteran was well oriented and casually dressed. Her mood was depressed and her affect was labile, tangential and was preoccupied with the behavior of others. She avoided emotional topics, her speech was within normal limits and her insight and judgment was intact. During a counseling session in late August 2010, the Veteran talked about her recent conversations with her daughter and was feeling positive about their improved efforts to communicate with each other. In September 2010, the Veteran expressed feelings of guilt and her decreased anxiety over the last couple of months. She also described her unstable relationship with a female friend and the lack of support from her friend, and of her desire to be self sufficient and to stay focused on her children and promoting her entrepreneurial ideas. When seen in October 2010, the Veteran reported that things were getting better and that she was handling them well. She reported that her divorce would be finalized the following month and that she will have all three kids. She said that she attended church regularly and was planning to take the kids on vacation the next week. She was not drinking alcohol and said that she had maybe two to three drinks since her mother's death. Mental status findings showed she was well oriented, her speech was normal in rate, rhythm and tone, and her memory was grossly intact. Her mood was anxious and her affect was ok. Her thought processes were logical and goal directed and her insight and judgment was fair. During a counseling session a few days later in October 2010, the Veteran discussed a recent confrontation with her sister the past weekend and how it was similar to what she experienced growing up. She discussed her sister's substance abuse and how it affected their relationship and her failed efforts with her sister. She also reported that she was in a new relationship and explored the differences with her current and past relationships and patterns of behavior. The Veteran appeared relaxed and was talkative and circumstantial, often changing the subject or storytelling. She was well oriented, casually groomed and her mood was ok. The assessment was depression with history of PTSD. When seen in November 2010, the Veteran continued to discuss her new relationship, behaviors that may signal her to end the relationship and her expectations from and toward her partner. She expressed awareness of her demeanor with her children and was comfortable with maintaining a distance during this stage of her new relationship. A VA psychiatric note in December 2010, included a list of the Veteran's problems, treatment plans, goals and objectives, and included diagnoses of bipolar disorder and history of PTSD. The GAF score was 59. The report did not include any clinical findings or indicate that the Veteran was actually evaluated on that date and appeared to be more of a summary of treatment plan. When seen in January 2011, the Veteran complained of worsening anxiety and wanted to refill her prescription of Alprazolam. The Veteran reported that she had her own jewelry business which required delicate work which made her anxious, and that the Alprazolam helped her to stay calm and focused on her work. She reported that her stressors were under control and that she usually manages them well, but that she was not able to go to her weekly counseling sessions over the holidays due to her business and was planning to restart her counseling. The examiner commented that the Veteran had been taking high dose of Alprazolam along with alcohol in the past and recommended sobriety from alcohol and a tapering of her medications. The Veteran stated that she was not abusing alcohol and was able to maintain her sobriety with Naltraxozone. She said her last drink was three days earlier. The Veteran's memory was grossly intact and there was no change in her mental status findings. The diagnoses included PTSD by history, bipolar disorder by history, status post military sexual trauma, and alcohol abuse, in early remission. The GAF score was 58. The examiner commented that he suspected alcohol abuse and discussed tapering off some medications with the Veteran. VA outpatient notes in March 2011 showed that the Veteran reported that she stopped taking several of her medications because they were worsening her symptoms. She said that she started having suicidal thoughts, but that they went away after she stopped taking Trazadone. She also said that she wanted a new psychiatrist. On an annual VA physical examination in April 2011, the Veteran reported that she had new sexual partners and requested STD testing. She reported her stressors included the death of her mother and trying to start two new businesses. When seen by VA psychiatric services in August 2011, the examiner noted that the psychiatrist who had been treating the Veteran previously, recommended tapering benzo medications and started her on Trazodone for insomnia, but that the Veteran had suicidal thoughts and nightmares on that medication and quit taking it. The Veteran reported her biggest desire was to be alert and creative, and got upset when discussing weaning her off her medications. The Veteran reported that she takes Naltrexone, but that she consciously decides not to take it when she wants to drink and said that her last drink was on the weekend. She said that she stopped going to women's group counseling because it was too "naggy" and that she stopped going to individual counseling because she didn't like it. She reported that she last smoked marijuana two to three years earlier. On mental status examination, the Veteran was well groomed, pleasant and cooperative. She was alert and well oriented, and her speech was of normal tone and pace. Her mood/affect was angry and anxious, her thought processes were linear and goal-directed, and her memory was grossly intact. Her intelligence and abstract thinking was average, and her insight and judgment was poor. The diagnosis was PTSD, and the GAF score was 55. An addendum report, dated in August 2011, noted that the Veteran admitted to smoking marijuana when she was evaluated in May 2010, and was told that she would have to undergo urine drug screens as part of the treatment plan. The Veteran was contacted in June 2010 to schedule an appointment, but declined to make an appointment at that time. The Veteran was contacted (today) to discuss treatment options for counseling and was reminded that she was offered counseling in June 2010, but said that she didn't recall that and commented that she had a bad memory. The Veteran went on to report that she was not getting anywhere with the psychologist at the Oklahoma City VAMC and that all the psychologist wanted to do was focus on her past and the Veteran wanted to focus on her military career because that's where her issues were. The Veteran was given contact information and said that she would call the Vet Center to schedule an appointment. The Veteran was evaluated on October 7, 2011 at which time the VA examiner assigned a GAF score of 50. As noted above, the Veteran was granted a 70 percent rating effective from October 7, 2011. Analysis The evidence showed that prior to January 6, 2010, the Veteran's psychiatric symptoms were manifested primarily by anxiety, depression, irritability with occasional anger outbursts and sleep disturbance. However, the records showed that the Veteran's symptoms were well controlled with medication and regular counseling. The records showed that the Veteran experienced increased symptoms on only a couple of occasions, primarily when her medications were either changed or her therapists considered tapering her off altogether. She also had some increased symptoms after the death of her cousin in 2008, and the death of her mother in 2010. However, even on those occasions, the Veteran reported that her symptoms were stable with her medications, and that things were improving in her life and felt more in control. While the Veteran reported that she has serious memory problems, for example, forgets to take her medications, feed herself or her children, or how to spell simple words (see December 2009 letter), there was no objective evidence of any memory impairment in any of the medical reports of record. In fact, the Veteran's memory was described as grossly intact on every mental status evaluation during the entire pendency of this appeal. In this regard, the Board notes that despite being advised by VA on numerous occasions of the contraindications of alcohol consumption when taking her medications, including possible cognitive impairment, the Veteran continues to consume alcohol. In any event, there is no objective or clinical evidence to support the Veteran's claim that she suffers from any cognitive or memory impairment associated with her PTSD. Similarly, while the Veteran reported in December 2009, that she was "afraid to leave the house" and that on the "rare occasion" that she does leave home, she is in a "constant state of panic" and "extremely anxious" until she gets back home, she reported in May 2010 that she participates in spur of the moment activities and occasionally goes out with friends to local establishments. In October 2010, she reported that she attends church regularly and had plans to take a vacation with her children the following week. Her multiple marriages, notwithstanding, the fact that she goes to church regularly, takes vacation with her children and has entered into at least three new intimate relationships during the pendency of this appeal suggests that she not only goes out in public more than she alleges, but is able to establish effective social relationships. Moreover, this does not show that the Veteran is in a state of near-continuous panic affecting her ability to function independently, appropriately, and effectively. Likewise, in July 2010, the Veteran described her abilities to promote not only her husband's artistic talents, but her own personal talents and her efforts to increase her independence, including writing her memoirs and starting a new online hair accessory business. In January 2011, she talked about her jewelry business, and how she was so busy with it over the holiday season that she was unable to keep her therapy appointments. While the Board does not discount the impact of the Veteran's PTSD on the her daily activities, the fact that she has started two new businesses and is proud of her ability to promote herself and her businesses undermines the attorney's argument that the Veteran has difficulty establishing effective working relationships. The probative fact here is that the Veteran was not only capable of performing the mental acts required by employment but had the business acumen to create a business during this period. The Board reviews the RO's findings on a de novo basis and is not bound by the RO's findings. As to the attorney's assertion that the Veteran's multiple marriages shows that she has difficulty establishing and maintaining effective social relationships, there is nothing in the record that suggests her failed marriages were a manifestation of her PTSD. On the contrary, the record suggests that the Veteran's problems with interpersonal relationships were a manifestation of her strained relations with her mother who reportedly abused alcohol and an absent father dating back to childhood. In October 2005, the Veteran reported a long history of physical and emotional abuse dating back to childhood, and described herself as a "people pleaser" and always trying to fix or please her partners. In December 2005, the VA counselor indicated that the Veteran used relationships to fill the void of the need for her mother. The Veteran reported that she was the care-taker for her mother and sister growing up, and that this was a pattern she continued with her current relationships, particularly with men. The Veteran acknowledged that her disappointments in the men she has chosen was because they failed to fulfill the fatherly role that she expected for her son. The fact that the Veteran was married when she was 17 years old, divorced at 19, and was involved with her second husband prior to the beginning of the sexual harassment in service, would seem to confirm her description of a pattern of behavior that developed out of her childhood experiences rather than as a manifestation of her PTSD. That is, the Veteran reported that the harassment began when she was assigned to Ft. Sill, which according to her personnel records was on October 25, 1993. Although the Veteran did not marry her second husband until December 1993, she would have been in her first trimester when they married, as her daughter was born in May 1994. Therefore, it is reasonable to presume that the Veteran was intimately involved with her second husband prior to the sexual harassment in service. Based on the Veteran's statements and the counseling notes of record, the Board finds that the evidence weighs against the attorney's assertions that the Veteran's failed marriages were a manifestation of her PTSD thereby warranting a higher rating. The record shows that the Veteran's strained relationship with her mother and sister dated back to childhood and has been further complicated by her mother's alcoholism and her sister's substance abuse. (See, e.g., October 2010 counseling note). Nonetheless, the evidence shows that the Veteran continues to try to establish and maintain an effective relationship with her sister, and that she did the same with her mother up until her death. While the Veteran has occasional problems with her teenage daughter, the record showed that their relationship has improved significantly since it was discovered that her daughter suffers from bipolar disorder. The fact that she is sometimes troubled by the actions of her teenage daughter is not unusual between a mother and daughter, and is not a basis to conclude that the Veteran is unable to have an effective relationship because of her PTSD. The Veteran has never described any problems in her relationship with her son, and reported that her difficulties with one female friend stemmed from her friend's lack of support. The record shows that the Veteran has maintained a core group of female friends that she can turn to for support, that she continues to work on her relationship with her teenage daughter, and that she has entered into at least three intimate relationships with strangers during this appeal. While some of her relationships with men have not fared well in the past, the record shows - and the Veteran admits, that the failures were largely due to her choice in men and her expectations arising from her poor relationship with her mother since childhood. The Veteran has shown insight into her problems. While the Veteran's attorney argued that her alcohol abuse was indicative of impaired impulse control, which would satisfy one of the criteria for a 70 percent rating, he has not provided any medical evidence that the Veteran's alcohol use was related to her PTSD. Moreover, none of the healthcare providers have ever indicated or suggested the Veteran's alcohol use was a manifestation of impaired impulse control or was otherwise related to her PTSD. While the record includes a diagnosis of alcohol abuse in August 2010, the same provider in January 2011, indicated only that he suspected alcohol abuse. Thus, while the evidence of record raises a question of potential alcohol abuse, there is no clear diagnosis, nor has the Veteran ever alleged alcohol abuse secondary to her PTSD. The evidence shows that the Veteran takes a medication specifically to stop drinking. However, she indicated on multiple occasions that when she wants to have a drink, she makes a conscious decision to stop taking her medication on those occasions. The Veteran has been advised of the potential risks of alcohol consumption, particularly with her medications, has acknowledged that alcoholism runs in her family, that she is fully aware of the potential risks of drinking, and indicated that she takes measures to control her drinking. The record does not show that the Veteran suffered impairment from mixing alcohol and her medications. Under the circumstances, the Board finds that the evidence weighs against finding that the Veteran has impaired impulse control that would warrant the assignment of a higher rating. The Board has considered the December 2009 statement from the Veteran's former husband and his description of her symptoms and the effect that it had on their relationship. While the Board does not question the truthfulness of his observations and experiences, his description, when viewed in light of the clinical notes, does not show that her symptoms were of such severity to warrant a rating in excess of the 30 percent evaluation assigned prior to January 6, 2010. As discussed above, the Veteran has never been shown to have any memory impairment associated with her PTSD. As for her reported impatience, frustration and verbal abuse toward her husband, the Veteran's descriptions of her relationships and expectations are consistent with the symptoms she related dated back to childhood and the poor relationship she had with her mother. The evidence simply does not persuasively suggest or show that she manifested the severity of symptoms commensurate with the criteria for a rating of 50 percent rating prior to January 6, 2010. In this case, the Board finds that the Veteran's reported symptoms and the clinical findings on the various medical reports of record during the entirety of the appeal supports the assignment of a 30 percent evaluation, and no higher, prior to January 6, 2010, and no greater than 50 percent from January 6, 2010. Prior to January 6, 2010, the Veteran's symptoms were manifested primarily by anxiety, depression, irritability and occasional anger outbursts and sleep disturbance. However, the records showed that her symptoms were fairly well controlled with medications. Despite her reported anxiety when out in public or in crowds, the records showed that the Veteran goes out with friends to local establishments, attends church regularly, takes vacations with her children, has been in several intimate relationships, and started two home business - all during the pendency of this appeal. While the records showed that she had increased sadness and depressed mood following the sudden death of a cousin in November 2008 this post-service event is not related to the in-service military sexual trauma, and the clinical and mental status finding on all of the medical reports prior to January 2010, showed she was well oriented, that her attention and concentration was good, and that her thought processes were logical and goal-directed. The Veteran reported that she was focused on improving her relationships with her children and her mother despite their longstanding, strained history and her mother's alcoholism. In this case, the clinical findings prior to January 2010, did not show the frequency, severity or duration of psychiatric symptoms consistent with a rating of 50 percent or higher under the criteria cited above. Thus, the Board finds that an evaluation in excess of 30 percent prior to January 6, 2010, is not warranted. The Veteran's complaints and the clinical findings from January 6, 2010 to October 7, 2011, do not reflect any manifestations for the assignment of an evaluation in excess of 50 percent. The Veteran's symptoms were essentially the same as on the reports prior to January 2010, with the additional complaint of occasional panic attacks. There were, however, no reported symptoms or findings indicative of the manifestations required for an evaluation of 70 percent or higher. The record shows that the Veteran goes out with friends to local establishments, attends church regularly, and takes vacations with her children. Thus, the Board is not persuaded that the Veteran is in a state of near-continuous panic affecting her ability to function independently, appropriately, and effectively. While the record showed the Veteran reported that she had suicidal thoughts when her medications were adjusted in March 2011, she reported that the thoughts went away when she stopped taking Trazadone, and she did not report any further thoughts during the relevant periods addressed in this appeal. In short, the evidence of record does not show that the Veteran's symptomatology from January 6, 2010 to October 7, 2011 was reflective of the severity and persistence to warrant an evaluation in excess of 50 percent. The Board also observes that the Veteran's GAF scores during the relevant periods ranged between 50 and 65. A GAF score ranging from 41 to 50 is contemplated for serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning. A GAF score between 51 and 60 reflects moderate symptoms (e.g. flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning. A GAF score between 61 and 70 contemplates 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 with the household), but generally functioning pretty well, has some meaningful interpersonal relationships. See 38 C.F.R. §§ 4.125, 4.130 (incorporating the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition of the American Psychiatric Association in the rating schedule). Prior to January 6, 2010, the Veteran's GAF scores were primarily 60 with a single score of 65 in September 2008, and a single score of 55 in November 2008 (which was followed by a score of 60 in March 2009). The GAF scores are consistent with impairment that more nearly approximates mild, and the outlier score of 55 is consistent with intermittent periods of significant difficulty performing tasks under the 30 percent evaluation. From January 6, 2010 to October 7, 2011, the GAF scores ranged from 55 to 59 with a single score of 50 in April 2010 only to be replaced two weeks later by a score of 55. The GAF scores are consistent with impairment that more nearly approximates moderate with the 50 score representing an outlier or temporary exacerbation in functioning. The GAF score is an indicator of the examiner's assessment of the individual's overall functioning. As outlined above, the Board finds that when all of the evidence and findings contained herein are considered, including the degree of functioning as evidenced by the reported scales, the Board concludes that the Veteran has not been shown to have met the criteria for a higher evaluation in excess of 30 and 50 percent for her PTSD for the relevant periods in question. Based on the above analysis of the facts and findings in this case, the Board finds that the evidence does not show or otherwise suggest that the Veteran's PTSD symptoms were of such severity to warrant a rating in excess of 30 percent prior to January 6, 2010, or an evaluation in excess of 50 percent from January 6, 2010 to October 7, 2011. Accordingly, the Board concludes that the Veteran does not meet or nearly approximate the level of disability required for a higher evaluation for the appropriate periods from the initial grant of service connection. Therefore, the Board finds that the preponderance of the evidence is against the Veteran's claim. The Board has considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 3.321(b)(1). The schedular evaluations in this case are not inadequate. An evaluation in excess of the ratings assigned is provided for certain manifestations of the service-connected PTSD disability but the evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disability, as the criteria assess the level of occupational and social impairment attributable to the Veteran's symptoms. For the reasons discussed above, the Board finds that the schedular rating criteria adequately contemplate the impairment caused by the Veteran's psychiatric disorder for the relevant periods. In view of this, referral of this case for extraschedular consideration is not in order. See Thun v. Peake, 22 Vet. App. 111 (2008); Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996); see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Finally, the Board notes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Veteran was granted TDIU by the RO in December 2011; effective from January 6, 2010. Thus, the question in this case, is whether the Veteran's PTSD prior to January 6, 2010 was of such severity so as to preclude substantially gainful employment. In this regard, the evidence showed that the Veteran completed VA Vocational Rehabilitation training in October 2004, and that she worked as a dental assistant for approximately six months before resigning in September 2005, due to "health reason." Although the Veteran reported that she missed two to four weeks of work due to illness during that time, she did not provide any information or evidence as to the nature of her illness. Moreover, a statement from her former employer, received in January 2007 showed that the Veteran worked eight hours a day, 40 hours a week, did not miss any time from work, and that no concession were made to accommodate her for any disability. As discussed above, the Veteran was able to start her own business during this period. For the reasons discussed above, the Board finds that there is no credible evidence that the Veteran's PTSD symptoms prior to January 6, 2010 alone rendered her unemployable. Accordingly, the Board finds that further consideration of entitlement to TDIU is not warranted. (CONTINUED ON NEXT PAGE) ORDER An initial evaluation in excess of 30 percent for PTSD prior to January 6, 2010, is denied. An initial evaluation in excess of 50 percent for PTSD from January 6, 2010 to October 7, 2011, is denied. ____________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs