Citation Nr: 1337026 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 10-46 995 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD M. Caylor, Associate Counsel INTRODUCTION The Veteran had active service in the United States Marine Corps (USMC) from June 1967 to April 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which implemented the grant of service connection for PTSD and assigned a 10 percent rating as of January 18, 2006. In October 2010, the RO increased the rating to 30 percent as of January 18, 2006. The Veteran continues to appeal for a higher initial rating. The Board has reviewed the physical claims file and the Virtual VA electronic claims file. FINDING OF FACT The Veteran's PTSD is manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Procedural Duties VA satisfied its duty to notify the Veteran pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2013). Under the VCAA, VA must assist a claimant when he or she files a complete, or substantially complete, claim for benefits. This assistance involves notifying claimants of evidence that is necessary, or would be of assistance, in substantiating their claims, and providing notice that, if service connection is awarded, a disability rating and an effective date for the award of benefits will be assigned. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). In this case, since the grant of service connection was implemented and an initial rating was assigned for PTSD in May 2010, the claim has been substantiated and VA has already satisfied its duty to notify the Veteran. Dingess, 19 Vet. App. at 490-491. The filing of a notice of disagreement (NOD) with the initial rating of a disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Id. VA also satisfied its duty to assist the Veteran in the development of his claim. First, VA satisfied its duty to seek relevant records. The RO associated the Veteran's service personnel records (SPRs), service treatment records (STRs), private treatment records, and VA treatment records with the claims file. The Veteran has not identified any treatment records aside from those that are already of record; therefore, the Board concludes VA has made every reasonable effort to obtain all records relevant to the Veteran's claim. Second, VA satisfied its duty to provide a medical examination and obtain an opinion when required. In October 2010, VA provided the Veteran with a medical examination which addressed the current severity of his PTSD. The examination is adequate, as the report shows that the examiner considered the relevant history of the Veteran's symptoms and provided a sufficiently detailed description of the disability. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). As VA satisfied its duties to notify and assist the Veteran, the Board finds there is no further action needed to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A , or 38 C.F.R. § 3.159, and that the Veteran will not be prejudiced as a result of the Board's adjudication of his claim. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Merits of the Claim The Veteran contends he is entitled to an initial disability rating in excess of 30 percent for PTSD. When deciding a case, the Board must consider all evidence on both sides of an issue, base its decision on the entire record, and state the reasons or bases for any findings and conclusions on material issues of fact and law. 38 U.S.C.A. §§ 1154(a), 5107(b), 7104(a) (2013); 38 C.F.R. §§ 3.303(a), 3.304(b)(2), 3.307(b) (2013); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board must focus on the evidence necessary to substantiate a claim and what the evidence fails to show, and, in doing so, explain why any material evidence favorable to the claimant was rejected or given little weight. 38 U.S.C.A. § 7104(d)(1); Timberlake v. Gober, 14 Vet. App. 122, 129 (2000). But see Dela Cruz v. Principi, 15 Vet. App. 143, 148-149 (2001) (finding that the Board need not discuss every piece of evidence in the record). If VA determines that a preponderance of the evidence supports a claim, or if the claim is in relative equipoise, the claimant shall prevail. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). If a preponderance of the evidence is against a claim, the claim will be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). If there is an approximate balance of positive and negative evidence regarding any material issue, the benefit of the doubt goes to the claimant. Gilbert, 1 Vet. App. at 53-54. Disability evaluations are governed by VA's Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2013). The percentage ratings in the Rating Schedule represent the "average impairment in earning capacity" resulting from service-connected disabilities, and residuals thereof, in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2013). When assigning a disability evaluation, the Board must consider the potential application of any applicable regulation governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). During an evaluation, the symptomatology of a veteran's service-connected disability is compared with criteria set forth in the Rating Schedule and a percentage rating is assessed. 38 C.F.R., Part 4. If more than one percentage rating could apply, the higher one will be assigned if the disability picture more nearly approximates the required criteria for that rating. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses, the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. If, however, the multiple diagnostic codes each require "distinct and separate" symptomatology that does not duplicate or overlap with the symptomatology required in the other diagnostic codes, a veteran may be assessed multiple ratings. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). A veteran may also be assessed multiple ratings if multiple distinct degrees of disability occurred during the relevant period. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's PTSD is evaluated under the general rating formula for mental illnesses. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). Under 38 C.F.R. § 4.126(a), an evaluation of a mental disorder must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The assigned rating should be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). While the evaluation should consider the extent of social impairment, a rating should not be assigned based solely on social impairment. 38 C.F.R. § 4.126(b). Under the general rating formula for mental disorders, the following ratings apply. 38 C.F.R. § 4.130, Diagnostic Codes 9201-9440. A 30 percent rating applies if the veteran has 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, or recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating applies if the veteran has 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. Id. A 70 percent rating applies if the veteran has 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 worklike setting); inability to establish and maintain effective relationships. Id. Finally, a 100 percent rating applies if the veteran has 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. Id. The list of symptoms within the criteria for each rating is not exhaustive, so the impact of other symptoms particular to a veteran or a disorder on occupational and social functioning should also be considered. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition to these criteria, the Board must consider any reported Global Assessment of Functioning ("GAF") scores, which reflect psychological, social, and occupational functioning. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). GAF scores are highly probative, as they relate directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. Massey v. Brown, 7 Vet. App. 204, 207 (1994). GAF scores do not, however, necessarily mandate a 100 percent evaluation. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). GAF scores of 61-70 indicate some mild symptoms or some difficulty in social, occupational, or school functioning, with the ability to generally function pretty well and have some meaningful personal relationships. American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (4th ed. 1994). GAF scores of 51-60 indicate moderate symptoms, such as a flat affect, circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, as evidenced by having few friends and having conflicts with peers or co-workers. Id. GAF scores of 41-50 indicate serious symptoms, such as suicidal ideation, severe obsessional rituals, and frequent shoplifting, or serious impairment in social, occupational, or school functioning, as evidenced by having no friends and being unable to keep a job. Id. The Veteran has appealed the initial rating assigned for PTSD. The Board therefore considers evidence submitted from January 2006 (the date service connection was established) to the present. Fenderson, 12 Vet. App. at 119. In his January 2006 informal claim, the Veteran reported that he had nightmares, memory loss, and that certain triggers caused him to dwell on Vietnam. In April 2006, the Veteran underwent a VA compensation examination. The Veteran reported that he thought daily about his experiences in Vietnam, and that he had slept restlessly since Vietnam. He was "rather stressed" because the Ford Plant was "probably shutting down in the very near future." He had "some violent episodes while he was intoxicated," but none within the prior six years. He denied prior psychiatric hospitalizations, outpatient psychiatric/chemical dependency treatment, and primary care treatment for anxiety, depression, or sleep-related problems. He had taken Zyban for smoking cessation purposes, but stopped taking it because it made him highly anxious. He worked for Ford Motor Company as a manufacturing tech group leader/team leader and had worked there on a full-time basis for thirty-three years. He enjoyed fishing, woodworking, and recreational shooting, and used to belong to a gun range but let his membership lapse. He had three children from a prior marriage and had been married to his current wife for a six-year period of time. He had a very good relationship with his family. He also talked with some of his friends at work about some of his experiences in Vietnam. On objective examination, the VA psychiatrist examiner noted the Veteran was well-groomed and oriented to person, place, and time. He had no significant psychomotor retardation or agitation. His memory was intact. He was pleasant and cooperative, and interacted well during the evaluation. The VA examiner concluded that his activities of daily living were quite good and that he had no major problems with socialization skills; no significant avoidant behavior; and did not report using alcohol to self-medicate. It was concluded that the Veteran did not meet the diagnostic criteria for PTSD or any other psychiatric disorder, despite having a verified stressor. The assessment was alcohol disorder. The GAF score was 85, and it was determined the Veteran had no significant psychological factors or impairment in social or occupational functioning. During a December 2006 examination by a private psychiatrist, the Veteran reported that he worked for at least 12 hours a day, leaving for work at 3 a.m. and getting home at 9 p.m., and that he worked for fun and would "go crazy" if he could not work. He reported that he had accepted early retirement and would retire in September 2007. He gardened and fished, but was not interested in activities he used to enjoy and would work to fill his time. He felt detached from everyone aside from his wife and had a few work friends with whom he got along, but they were not close and did not socialize. He thought daily about Vietnam and the people with whom he was there. He was easily irritated, short-tempered, and got mad "for no reason." He avoided people, especially crowds. He had anxiety and no elation and used alcohol to help with difficulty in falling and staying asleep. He had trouble sitting still and could not sit down and relax. He had trouble concentrating and often forgot directions and names. He denied flashbacks, panic, and prior mental health treatment for PTSD. On objective examination, Dr. B noted the Veteran had arrived an hour early and was clean-shaven and oriented to person, place, and time. He had reasonable judgment with some insight. He had logical but vague thought content, but his stream of speech was at times disorganized because he needed notes to "keep straight what happened when" in Vietnam. He had a depressed mood and an apparent flat and expressionless affect. He could make some eye contact, but was very hard to interview. Dr. B found that the Veteran alluded to nightmares and intrusive thoughts about Vietnam, but that he had no psychological distress when dealing with the VA or watching war films. He had sleep problems because nightmares woke him up one to two times per week; some hyperactivity due to avoiding groups of people; hypervigilance because he felt others might have been "out to get him"; and possibly a delusion or perceptual disorder because he was suspicious or paranoid about others. He had a meaningful relationship with his wife, but not with most of his family, and he had no friends. Dr. B concluded that the Veteran had chronic PTSD, alcohol abuse/overuse, and stressors that included the Iraq War and his expected retirement from Ford. Dr. B found his PTSD was mild, but was being exacerbated by his expected retirement and the Iraq War. Dr. B used an American Medical Association (AMA) Guide to determine that his activities of daily living were impaired by 10-20 percent, which was compatible with most useful functioning; his concentration and adaption were impaired by 25-50 percent, which was compatible with some, but not all, useful functioning; and his social functioning was impaired by 55-75 percent, which showed significantly impeded useful functioning. His whole-person impairment based on PTSD was 32 percent. He had a serious disruption in social functioning that was significantly affected by his PTSD. His PTSD caused moderate sleep, concentration, and adaptation problems. He had worked 50-70 hours per week to deal with his PTSD and generally functioned satisfactorily at work, with routine behavior, self-care, and normal conversation. He had both occupational and social impairment with reduced reliability and productivity due to: a flattened affect; circumstantial or circumlocutory speech; disturbances of motivation and mood; difficulty establishing and maintaining effective work, social, and family relationships; a depressed mood; suspiciousness; chronic sleep impairment; and mild memory loss. Dr. B assigned the Veteran a GAF score of 60. During a July 2009 examination with a private psychologist, the Veteran reported that after 35 years he had retired from Ford Motor Company and that he worked for a landscaper mowing lawns for 40-50 hours per week. He changed his clothes and bathed daily. His marriage was pretty good, with ups and downs, and he shared decision-making with his wife. He had contact weekly with his younger son, monthly with his daughter and no contact with his older son. He had problems sleeping daily, including having nightmares and waking up during the night. He had a daily hyperstartle response and hypervigilance all the time. He had flashbacks two to three times per week. He had anxiety that consisted of an unexplained racing heart beat and increased sweating around three times per week. He had apprehension of height, crowds, water, and closed spaces. He was irritable and had angry feelings he tried to keep from others and anger episodes on a routine basis. He reported suicidal ideation in the past, but no attempts. He had to keep his tools and equipment in the same place all the time and did a nightly perimeter check at his house. He denied any loss of work due to his PTSD and denied having homicidal thoughts or intent. He reported that he had never sought counseling because he felt doing so would be giving in to a vulnerability that he had not chosen to admit to or show others. On objective examination, Dr. M noted the Veteran had arrived punctually and was dressed casually, clean-shaven, and oriented to person, place, and time. He had typical speech that was appropriate in volume and pace. He did not evidence communication difficulties and provided the necessary detailed information. He presented as compliant, truthful, cooperative, and anxious. He had a fair grasp of current events, could do serial subtraction without error, and could recall the last three presidents. He demonstrated poor short-term memory because he could only recall two out of five items after five minutes. Dr. M conducted a Detailed Assessment of Posttraumatic Stress and assigned the Veteran T-scores based his responses. T-scores higher than 65 were considered significant. Dr. M assigned the Veteran a 123 for posttraumatic stress, which indicated that the overall severity of his symptoms was in the severe range; a 122 for overall avoidance, which indicated his avoidance symptoms were significant; a 121 for re-experiencing, which indicated that his posttraumatic stress was significant and he was bothered regularly by intrusive recollections of the event; a 116 for hyperarousal, which suggested he experienced tension, irritability, or a tendency to be jumpy/on edge; a 111 for posttraumatic impairment, which indicated that the index trauma had significant effects insofar as his ability to function on an ongoing basis was compromised. Dr. M found the Veteran's scores suggested he was experiencing an unusual number of atypical symptoms. Dr. M concluded that the Veteran had PTSD with significant symptoms, such as nightmares; flashbacks; a hyperstartle response; hypervigilance; irritability; and anger and alcohol dependence. According to an AMA Guide, the Veteran's level of psychological impairment was 40 percent, or moderate, which was compatible with some but not all useful functioning. Dr. M found the Veteran had difficulty with activities of daily living on an ongoing basis, as he had difficulty with sleep, attachment to others, flashbacks, hyperstartle, and hypervigilance. He had "obsessive traits," or ruminative thoughts and behaviors that were centered on his activities of daily living. He had interpersonal difficulty adapting to stressful circumstances; a lessened ability to establish and maintain effective non-family interpersonal relationships that were close; and problems functioning as effectively as he might otherwise perform. He had a hyperstartle response and hypervigilance as was "ever alert for possible danger," but did not have paranoid thinking, delusions, hallucinations, or a personality disorder. In a March 2010 addendum opinion, Dr. M clarified that he had used the DSM-IV to assess the Veteran with PTSD and that his stressors were psychosocial problems. Dr. M assigned a GAF score of 65 that applied over the prior year. In October 2010, the Veteran underwent a second VA compensation examination. The Veteran reported working as a delivery driver at an auto parts store three days per week for 10 hours for around seven months. He got along with coworkers and supervisors and had "no problems performing his job duties." He had retired from Ford Motor Company in July 2009 because it had closed the plant and relocated. He had quite a few arguments with people at Ford and drank on the job, and felt his alcohol use had impacted his work. After retiring, he worked driving a dump truck, but quit the job because he had not gotten along well with his boss. They had a heated discussion and one "close call" regarding a physical fight. After that, he worked mowing grass for a couple of years, but had not gotten along with that boss, either. He had been married for ten years. He had no friends, did not engage in social activities, and had no regular contact with anyone else. He spoke with his sister a couple of times per year and did not see his children often. When he was not working, he would mow the lawn or clean his garage. He enjoyed doing household projects and watching television. He helped his wife with household chores and had no major problems with hygiene or self-care. He used alcohol to cope with his PTSD symptoms. He reported having daily distressing recollections of traumatic combat experiences in Vietnam. He had monthly distressing dreams or nightmares and a mildly depressed mood on most days. He had mild memory difficulty and would forget the third out of three deliveries. He slept approximately three hours per night and had difficulty falling and staying asleep. His mood for many years and during the prior month had been "mostly irritated" on most days. He had a low level of interest in things and had for years, and his energy level was low about 50 percent of the time. He endorsed having intense psychological distress and physiological reactivity on exposure to cues and having hypervigilance and an exaggerated startle response. He endorsed avoiding crowds and making efforts to avoid thoughts, feelings, or conversations about his trauma. He endorsed having markedly diminished interest or participation in significant activities and feeling detached or estranged from others on most days. He endorsed having a restricted range of affect on most days. He endorsed having an inability to recall important aspects of his trauma and having a "sense of foreshortened future. He was not sure whether he was having panic attacks. He denied any mental health treatment or periods of remission since his last examination. He denied post-military traumas and suicidal or homicidal ideation, plan, or intent. He denied acting or feeling as if his trauma were recurring. He also denied missing work during the past year for mental health reasons, coming in late or leaving early, or being counseled or reprimanded at his job. On objective examination, the VA examiner noted that the Veteran was alert and oriented and casually, cleanly, and appropriately dressed. He had psychomotor activity that was within normal limits and an unremarkable speech rate, volume, and tone. He had a euthymic mood, a congruent and appropriate affect, and cooperative and appropriate behavior. He had good eye contact and good communication and his thought content and process were unremarkable. He was a good historian and showed no signs of delusions or hallucinations. The VA examiner concluded that the Veteran had PTSD and alcohol abuse, with a stressor that was having minimal social support. The VA examiner found he was independent in activities of daily living and that his description of periods of anxiety was inconsistent with a panic attack. PTSD had a mild impact on his social and occupational functioning. He had mild attention and concentration problems and his hypervigilance was mild. The impact of his decreased level of interest in activities and his irritability on his motivation to engage in activities with others was mild. His efforts to avoid thoughts, feelings, or conversations regarding his trauma was mild, as he was comfortable talking about his experienced with other Vietnam veterans. The VA examiner noted that the Veteran had worked for 35 years at Ford; his job at the auto parts store was going well; he denied missing work for mental health reasons; his alcohol use did not appear to impact his work functioning or cause legal problems. While he reported not getting along with two prior bosses, he had no significant problems with working relationships. His attention and concentration problems might have a mild impact on his productivity and efficiency. The October 2010 VA examiner assigned a GAF score of 61. Based on these criteria, the Board finds the Veteran not entitled to a disability rating higher than 30 percent for his service-connected PTSD throughout the entire period on appeal. The Veteran has occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to a depressed mood; anxiety; suspiciousness; chronic sleep impairment; and mild memory loss. Despite an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the Veteran was gainfully employed and able to function satisfactorily, independently, appropriately, and effectively during essentially the entirety of the period on appeal, with routine behavior, self-care, and normal conversation. Consideration has been given to assigning a higher disability rating, but the Board finds the record evidence does not show that the Veteran experienced occupational and social impairment with reduced reliability and productivity. The Veteran was gainfully employed during essentially the entirety of the period on appeal-he worked in a leadership position at Ford for 50 or more hours per week and retired only because the plant closed; quit a job working as a dump truck driver; and then worked for a landscaper for over 40 hours per week for several years before working for 30 hours per week in an auto parts store. In addition, he worked "for fun" and never missed work for mental health reasons. While the Veteran asserted in his November 2010 notice of disagreement (NOD) that his problems remembering directions caused an "inability" to be productive at the auto parts store, he also reported during the October 2010 VA examination that he did not have problems showing up to and staying at work; had not been counseled or reprimanded; and had "no problems performing job duties" at the auto parts store. Moreover, every examiner found the Veteran was able to function well at work. The April 2006 VA examiner found no impairment of occupational functioning. The December 2006 private examiner, Dr. B, found he functioned satisfactorily at work and needed to work to avoid thinking about Vietnam. The July 2009 private examiner, Dr. M, found the Veteran did not function as effectively as he might have without PTSD, but was able to function "pretty well." Finally, the October 2010 VA examiner found his problems with attention and concentration did mildly impact his efficiency and productivity, but that his job was going well, he had no issues with working relationships, and his alcohol use did not affect his work. The Veteran did have some difficulty in establishing and maintaining effective work and social relationships-he quit two post-retirement jobs because he did not like his bosses; avoided crowds, had no friends and did no social activities; was easily irritable and suspicious of non-Veterans; and did not talk to his oldest son-but he did not have an "inability" to do so, as he maintained an effective relationship with his wife; was in contact with his two younger children and sister; had friends at Ford with whom he had talked about Vietnam; got along with his supervisor at the landscaping business enough to stay there for several years; and got along with most of his coworkers and supervisors at the auto parts store, despite not liking some people there. Further, the Veteran's relationship with his immediate family was largely intact during the entirety of the period on appeal. The December 2006 private examiner, Dr. B, found his relationship with his wife was meaningful. During the July 2009 private examination, the Veteran reported his marriage had ups and downs but was pretty good and that he shared decision-making with his wife. While he reported that he did not have contact with his older son, he also reported weekly contact with his younger son and monthly contact with his daughter. Similarly, while he reported during the October 2010 VA examination that he did not see his children often, he also reported having a relationship with his wife and speaking with his sister. In addition, the Board finds the Veteran did not have circumstantial or circumlocutory speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of long-term memory; impaired judgment; or impaired abstract thinking. While the December 2006 private examiner, Dr. B, did find the Veteran had circumstantial or circumlocutory speech, that finding is not echoed elsewhere in the record. The April 2006 VA examiner found no psychomotor retardation; the July 2009 private examiner, Dr. M, found his speech was typical; and the October 2010 VA examiner found his speech unremarkable. Similarly, while the Veteran asserted in his November 2010 NOD that he had more than one panic attack per week, the record does not appear to support his assertion. Panic attacks are not noted elsewhere in the record, and the Veteran denied panic during the April 2006 and December 2006 examinations. Further, the October 2010 VA examiner found his descriptions of periods of panic were not consistent with panic attacks. Finally, although some examiners found the Veteran had mildly impaired short-term memory and some difficulty concentrating, none of the examiners found he had impaired long-term memory; difficulty in understanding complex commands; impaired judgment; or impaired abstract thinking. Despite finding the Veteran had difficulty providing an organized history, the December 2006 private examiner, Dr. B, found he had reasonable judgment with some insight, and logical, albeit vague, thought content. Dr. B also found the Veteran may have had a delusional or paranoid disorder, but this finding is not echoed elsewhere in the record and during the April 2006 VA examination the Veteran denied delusions and hallucinations. The July 2009 private examiner, Dr. M, found no delusions, hallucinations, or paranoid thinking. The October 2010 VA examiner found he had no inappropriate behavior, delusions, or hallucination, and his thought process and content were unremarkable. The Board acknowledges the Veteran's assertion in his November 2010 NOD that his short-term memory impairment was "severe," but finds he is not competent to diagnose the severity of his memory impairment. Jandreau v. Nicholson, 492 F.3d 1372, 177 n.4 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). The Board also recognizes that in the July 2009 private examination the Veteran reported nightly perimeter checks and a need for his tools to be in the same location all of the time, but notes that, while the private examiner, Dr. M, found these were "obsessive traits" and behaviors that caused difficulty with activities of daily living, Dr. M did not find they were obsessional rituals and still found the Veteran functioned pretty well. Further, no obsessive traits or rituals were discussed during the April 2006, December 2006, or October 2010 examinations, and the Veteran did not include them in his NOD or substantive appeal. Similarly, while the Veteran reported suicidal ideation without an attempt during the July 2009 private examination, the record does not appear to support his assertion, as he denied suicidal ideation or plans during the April 2006 and October 2010 VA examinations and, moreover, he did not include them in his NOD or substantive appeal. Moreover, throughout the entire period on appeal the examiners assessed the Veteran with GAF scores indicating only mild or moderate symptoms. The April 2006 VA examiner assigned a GAF score of 85 and found no significant impairment. The December 2006 private examiner, Dr. B, assigned a GAF score of 60, indicating moderate symptoms, and found he generally functioned satisfactorily at work with routine behavior, self-care, and normal conversation, even though he had occupational impairment with reduced reliability and productivity, a potential delusional or paranoid disorder, and moderate problems with concentration and adaptation. In the March 2010 addendum, the July 2009 private examiner, Dr. M, assigned a GAF score of 65, indicating mild symptoms over the prior year, and found he functioned pretty well, despite difficulty with activities of daily living; suicidal ideation with no attempts; some obsessive traits; interpersonal difficulty adapting to stressful circumstances; a lessened ability to establish and maintain close, non-family personal and work relationships; a hyperstartle response; constant hypervigilance; flashbacks two to three times per week; daily nightmares; and three periods of anxiety per week. Finally, the October 2010 VA examiner assigned a GAF score of 61, indicating mild symptoms, despite finding that his attention and concentration problems may have mildly impacted his efficiency and productivity. The Board therefore finds that a disability rating in excess of 30 percent is not warranted at this time. 38 C.F.R. § 4.130, Diagnostic Code 9411. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a higher schedular rating. Fenderson, 12 Vet. App. at 126-127; Hart, 21 Vet. App. at 511-512. The Board recognizes the discrepancy between the April 2006 VA examiner's assigning a GAF score of 85 and finding of no symptoms or diagnosis of PTSD and therefore no significant impairment, and the December 2006 private examiner's diagnosis of PTSD, assigning a GAF score of 60, indicating moderate symptoms, and finding of reduced reliability and productivity. The Board notes, however, that the Veteran later indicated that he suffered from multiple symptoms throughout the period on appeal and had not sought treatment to avoid having to show weakness. The Board finds the Veteran competent to provide symptoms and that his statements regarding his symptoms during that period were credible; therefore, the Board gives them probative weight and does not find it necessary to stage the Veteran's PTSD rating during that period. The Board also finds that the claim does not need to be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The Board must refer a claim if (1) a service-connected disability presents such an exceptional disability picture that the available schedular ratings do not reasonably describe or contemplate the severity and symptomatology of the disability, and (2) the disability picture exhibits other factors, such as marked interference with employment and frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111, 115-116 (2008). In this case, the Veteran's disability picture is not exceptional or unusual. The competent objective medical evidence of record reflects that the schedular criteria contemplate the manifestations of the Veteran's service-connected PTSD, and there is no indication that the average disability would be in excess of that contemplated by the assigned 30 percent disability rating. Further, the record does not show frequent hospitalizations or emergency room visits for the Veteran's service-connected PTSD and there is no evidence of incapacitating episodes. The Veteran was gainfully employed throughout almost the entirety of the period on appeal and did not report missing any work for mental health reasons. Accordingly, the referral of this case for extra-schedular consideration is not in order. The Board has considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) has been raised. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to TDIU is raised where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). However, TDIU is not raised in an increased rating claim unless the Roberson requirements are met. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). Here, the Veteran is employed. Thus, the matter of TDIU is not raised. ORDER Entitlement to an initial disability rating in excess of 30 percent for PTSD is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs