Citation Nr: 1337112 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 08-08 162 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an initial disability rating greater than 50 percent for service-connected posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from November 2000 to November 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In January 2008, the Veteran's disability rating was increased to 50 percent, effective August 31, 2007, the date VA received the Veteran's claim for service connection for PTSD. The Veteran continued his appeal for a higher rating. AB v. Brown, 6 Vet. App. 35, 38 (1993). In January 2011, March 2012, and December 2012, the Board remanded the case to the RO for additional development. Additionally, in May 2013, the Board requested a medical expert opinion from the Veterans Health Administration (VHA) pursuant to 38 C.F.R. § 20.901 (2013). As the requested development has been substantially completed, no further action is necessary to comply with the Board's directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDING OF FACT From August 31, 2007, the effective date of the award of service connection, the Veteran's PTSD is shown to be productive of a disability picture that more nearly approximates that of occupational and social impairment in most areas such as family relations, judgment, thinking, or mood. CONCLUSION OF LAW The criteria for an initial rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013), and implemented in part at 38 C.F.R § 3.159 (2013), amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Where, as here, the appeal stems from notice of disagreement with the award of an initial disability rating following the grant of service connection, further VCAA notice is not required. 38 C.F.R. 3.159(b)(3). Rather, the Veteran's appeal as to the initial rating assignment triggers VA statutory duties under 38 U.S.C.A. § 5104 and § 7105. In this regard, a statement of the case was issued in January 2008 which set forth the diagnostic code criteria to be satisfied to warrant a higher initial rating for PTSD. No further notification is necessary. Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained service treatment records, VA records, and the Social Security Administration (SSA). The Veteran underwent VA examinations in November 2007, February 2009 and October 2009. As indicated previously, in June 2013, in accordance with 38 U.S.C.A. § 7109 and 38 C.F.R. § 20.901, the Board obtained a VHA medical expert opinion. The Board finds that the medical expert opinion a review of the Veteran's medical history, including his service treatment records, and discussion of sufficient findings to rate disability. Specifically, the VHA expert has provided guidance to the Board regarding different mental health diagnosis and GAF scores. Therefore, the Board concludes that the VA examinations and VHA opinion combine to be adequate and allow the Board to make a fully informed decision. 38 C.F.R. § 4.2 (2013); see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In July 2013, the Veteran was provided a copy of the VHA opinion and afforded the opportunity to submit additional evidence and argument. The Veteran has not responded. As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2013). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). When evaluating the level of disability from a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign an evaluation based solely on the basis of social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130 (2013). PTSD is rated under Diagnostic Code 9411 under the General Rating Formula for Mental Disorders. The criteria for a 50 percent rating are 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; and difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent are occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. The criteria for a 100 percent rating are 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. The evidence considered in determining the level of impairment from PTSD under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411 and the General Rating Formula. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994).) The Global Assessment of Functioning (GAF) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DSM-IV. GAF scores between 31 to 40 indicate some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g. suicidal ideation or severe obsessional rituals), or any other serious impairment in social or occupational functioning. GAF scores from 51 to 60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). GAF scores ranging from 61 to 70, for example, reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. While the GAF score is relevant evidence, the GAF score alone is neither statutorily nor regulatory controlling in rating a psychiatric disorder, rather the rating is determined by the application of the Rating Schedule, 38 C.F.R. Part 4, as explained above. Neither the number of symptoms, nor the type of symptoms, nor the GAF score controls in determining whether the criteria for the next higher rating have been met. It is the effect of the symptoms, rather than the presence of symptoms, pertaining to the criteria for the next higher rating, that is determinative. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the evidence considered in determining the level of impairment from PTSD under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. Facts The Veteran's PTSD has been rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, as 50 percent disabling, effective August 31, 2007 when service connection was established. At all relevant times, the Veteran asserts that his disability is more severe than indicated by the 50 percent rating. The evidence reflects the Veteran first sought treatment in August 2007 because of paranoia and anger. His children aggravate him with the aggravation and impulsivity increasing after the birth of his second child. He denied destructive behavior to himself and his family. He did not have any suicidal or homicidal ideation, but did have nightmares. He also complained of difficulty sleeping. That month, he underwent a mental health intake evaluation. At that time, he complained of sleeping difficulties, irritability, and anger control. He worked full time as a carpenter but it is not steady work. He will complete a job and then is on a list until called to the next job. He had neither suicidal thoughts nor thoughts about harming someone. He described a lack of emotion with events such as his newborn son. There was no substance abuse or gambling problem. The evaluator noted the Veteran had good insight and judgment and his memory was intact. The diagnosis was PTSD and a GAF score of 61 was assigned. The Veteran was first afforded a VA examination in November 2007. During the examination, the Veteran reported having intrusive memories, recollections, flashbacks, and nightmares pertaining to his experiences in service. He stated that he was hypervigilant and hypersensitive to sounds and often woke up sweating. The VA examiner found the Veteran to be alert and oriented to time, place, and person. No delusions, psychosis, hallucinations, or suicidal or homicidal ideations were present. The examiner determined that the Veteran met the criteria for an Axis I diagnosis of PTSD as set forth in DSM-IV. The examiner also provided a GAF score of 62, which he stated reflected the impact of the Veteran's PTSD on his social problems. Also in November 2007, the Veteran reported symptoms of irritability/rage attacks, poor sleep (agitated with regular, intrusive memories of combat), and detachment/emotional numbing. As to the irritability, he hits walls and breaks things but rarely has grabbed family members. His temper stays elevated the rest of the day. Medication has helped his sleep. The Veteran also had an exaggerated startle response, hypervigilance, and panic attacks 1-2 times a month. The Veteran did have a circle of 15 to 20 friends from school. He enjoys softball. He described his mood as up and down but it is improved when gainfully employed as there is less financial and marital stress. The examiner noted that the Veteran had good eye contact and a reactive, full range, and stable affect. His thought process was linear and coherent. Another note indicated the Veteran had problems with unfamiliar places or large stores and malls. He was easily angered with his five year old daughter. He stated his depression may be related to not working. When he finished one job, he might not be called back and will be unemployed for a period of time. This leads to him becoming anxious and nervous about bills. The mental health care provider assigned a GAF of 60. VA received statements from the Veteran's wife and mother in November 2007. The wife stated that before deployment to Iraq, the Veteran never lost his temper but now does so at least once a day with her and their children. At times he punches something or breaks something. She described episodes where the Veteran squeezes the neck of their daughter when she misbehaves. She has taken over punishing the daughter. The Veteran also seems paranoid and cannot relax. He does not like unfamiliar or isolated places. She stated the Veteran did not like moving around to different jobs in his employment as a carpenter. He prefers a long term job and has turned down short term jobs. The Veteran also appeared to be more forgetful and his ability to pay attention is less. His mother also reported seeing the Veteran lose his temper over inappropriate matters. He has an inability to relax in public. In a December 2007 VA treatment record, it was noted the Veteran was not working due to a lack of carpenter jobs in his area. He had been feeling better until laid off. He yells and fights with his wife and children. At times, he bangs his fists against the walls, frustrated and overwhelmed with his financial situation. He had passing thoughts about suicide, but the thoughts pass and he was mainly saddened and depressed about not being able to care for his family. He spoke in a soft quiet voice with short conservative responses to questions. The provider stated the Veteran had a depressed mood flat affect but had logical, clear and concrete thoughts, and no perceptual disturbance, suicidal ideation, or homicidal ideation. In his January 2008 notice of disagreement, the Veteran reported that his psychiatric disability interfered with his ability to seek out or to sustain gainful employment. He stated he has no motivation to look for work and when he does, his condition interferes with his ability to function as required by the employer. He stated that his wife felt that his hygiene was unacceptable. Often times he would forget when he last performed hygiene-related activities, or just did not care to take care of himself in that manner. He reported suicidal thoughts and ideations, as well as thoughts of harming others. He reported a depressed mood and panic attacks a few times a week. He stated that he did not feel the need to interact with his friends or family, and found it hard it maintain any kind of relationship with them. The Veteran indicated that he would drink often and took significant amounts of medication for his PTSD. He stated that he felt numb and emotionless, and often experienced unprovoked, and at times violent, outbursts of anger directed towards his wife and children. Also in January 2008, the Veteran submitted a statement from his wife, who offered her observations of the Veteran's symptoms. She stated that the Veteran regularly had emotional outbursts of anger during which he would punch walls and doors, curse, and yell. She reported that the Veteran had nightmares several times a week, which had increased in frequency and severity in the past few months. She stated that the Veteran's sleep was restless and that he would wake in panic, sweating. She reported he had panic attacks no less than two or three times a week and headaches a few times a month. She stated that the Veteran kept to himself, rarely socializing with family or friends. She indicated that he was easily angered and frustrated when in public. She further indicated that he was apathetic and "emotionally numb." She stated that the Veteran's mood impacted his relationship with their children and that divorce was frequently discussed. A VA psychiatry treatment note dated in January 2008 indicated that the Veteran had presented with symptoms of irritability and rage attacks, poor sleep, intrusive memories of combat, and detached and emotional numbing. It was noted that he was still unemployed and the financial stress of which he believed made him easily annoyed with long lines and traffic. He reported being verbally aggressive in traffic, but denied ever losing control of his temper completely. Being with his wife and children helped him control himself. He reported regular vivid flashbacks and nightmares every other night. His mood was angry and depressed. He had occasional thoughts of suicide, but no intention or plan. The VA psychiatrist noted that the Veteran's speech and motor skills were within normal limits and that his affect was not congruent. He was able to smile and laugh at times. His insight and judgment was good. He assigned a GAF score of 50. Later that month, he started a job and thought he was less irritable although he is easily frustrated with co-workers or family members. A February 2008 VA mental health treatment note includes a GAF score of 60. Another note entered that month indicated he had a good work ethic when work was available. His limitations included uncontrolled anger and at times, excessive drinking. There was one incident where he put his hands on his wife's neck while fighting with his wife. He reports fatigue after work and does little in child care or house chores and felt angry most of the time. He was calm and cooperative but initiated little conversation on his own with short conservative responses. He had a depressed mood, flat affect, clean and coherent thoughts that were logical without perceptual disturbances or suicidal or homicidal ideation. He stated that money problems and being yelled at by co-workers triggered his PTSD and anger problems. Later that month, he reported he has uncontrolled anger and gets angry at work. When he returns home, he is easily irritated by anything his children are doing. He did report a slight improvement in his relationship with his wife and actually enjoyed going to family gatherings. He has not physically hurt or touched his wife or had volatile active angry outbursts. In March 2008, the Veteran reported he was unable to work much as he was easily irritated and prone to verbal arguments with other workers. He claimed to be too stressed to work the whole day or more than two days a week. His current job was indoors which afforded him more consistent hours although he stated he could not do the work. The Veteran reported it takes him two hours to fall asleep and will awaken with the slightest noise. The nurse practitioner noted the Veteran had a blank, stoic look. He had short, conservative responses, depressed mood, and flat affect but had clean and coherent thoughts and was logical. The Veteran was seen in April 2008 for an initial mental health evaluation. At that time, he presented with a broad range of symptoms related to his PTSD, which he stated had been increasing in severity since service. He particularly reported increasing problems with anger management, impulse control, depression, and sleep impairment. He reported that he has fights on job sites and this leads to avoidance of a job site as soon as he thinks he has problems with somebody. He does not work due to his fear of losing his temper. During the evaluation, the Veteran reported that his relationship with his wife was strained, but that both were committed to the relationship and separation had not been discussed. He had pulled back from most social relationships but kept in phone contact with a friend from service. He was severely limited in leisure pursuits by his depression and hypervigilance. The Veteran presented with serious depression and had flat effect. He reported a depressed mood with regular suicidal thoughts, but these remained passive suicidal ideation. His primary problem was noted to be anger management impairment. He also presented with intrusive thoughts and memories, and nightmares about his military experiences, which involved extensive combat. The evaluator had an impression that the Veteran may be underreporting the severity of both his depression and suicidal ideation. Alcohol abuse was another contributing factor. He has never struck a family member, only grabbed them on occasion or thrown things. The Veteran appeared able to independently attend to self-grooming and attending to activities of daily living. The evaluator rendered an Axis I diagnosis of PTSD, secondary to combat experiences, and unspecified depression and assigned a GAF score of 35. He thought the Veteran had family support and noted the Veteran had strengths in keeping appointments, raising children, and possessing employable skills, On the other hand, he had few financial resources, While the speech was articulate and coherent, it was also flat with very brief, terse response to questions. He was focused on his anger problems and had feelings of hopelessness and frustration. The Veteran was described as having a depressed, irritable, and worried mood. His thought process was linear and logical. He had fair to poor judgment and poor impulse control. According to the Veteran, he had poor attention and concentration but no memory problems were reported by the Veteran. In April 2008, another note indicated the Veteran was working less and he did not even go in because too much bothered him. He stated everything bothered him. At times, he accompanies his family to the park but has to go back because he is unable to tolerate the park for too long. In May 2008, the Veteran was awarded monthly disability benefits from SSA. The records from the SSA include a mental health evaluation in April 2008. At that time, the evaluator noted the Veteran had marked limitations with social interaction and severe anger issues. The evaluator noted the Veteran had reached the point of physically exploding against his wife and young daughter. He had little motivation and has not kept jobs for any significant time since separation. He has little interest in interacting with his children, wife, or other family members. He has explosive anger outbursts on a daily basis and is very paranoid. Once angry, he remains that way for the duration of the day. He is easily rattled by noise hypervigilant, and keeps himself socially isolated. The evaluation listed the Veteran's diagnoses as PTSD, depression unspecified, alcohol abuse, and headaches. Based on a review of the evidence before the SSA evaluator, multiple clinicians noted the same range of symptoms of intrusive memories, hypersensitivity, hypervigilance, severe social unconformity, easy agitation, and general anxiety. His most serious symptoms were anger management and impulse control with severe aggressive behavior directed towards his family but he did have anger directed towards coworkers he believed provoked him. This caused absenteeism and job loss because the Veteran copes by abandoning the job. He also experienced road rage. The Veteran had minimal tolerance of crowds and people behind him. He was very avoidant of triggers and increasingly isolated. The Veteran also described the inability to concentrate or pay attention. The evaluator also stated the Veteran's emotional numbness may be causing the Veteran to be masking or under representing the severity of his symptoms. On the other hand, the evaluator said the Veteran had a strong work ethic and prognosis for entry into the workforce is positive if the Veteran can have intensive treatment to avoid violent behavior. In her interview with SSA, the Veteran's wife emphasized the Veteran has a severe problem with his temper and is simply unable to control it. He explodes on a daily basis over nothing and he has shoved both his wife and daughter. The wife feels she must stay home to protect the children because they act like typical children. He frequently has outbursts when they get on his nerves which is a few times a day. He punches walls and doors and takes no pleasure with interacting with his children. The Veteran typically spends his day on the couch staring at the TV but rarely paying attention to it. He does not help with household tasks and he does not shower or shave on a consistent basis. His wife has to ask him to do it. Every job he has had since returning from deployment has not lasted very long as he always "gotten into it" with co-workers and has either been fired or he stopped going. That same month, the Veteran's wife submitted a statement reporting that the Veteran drinks alcohol every day sometimes up to 6 in a day. It causes him to become angry more easily and careless with the children. He has been unable to hold consistent full-time work and rarely leaves their house. He seems to fear public places and strangers also irritate him. He also becomes angry when driving so the wife does the driving. She believes she cannot obtain a job because she has to stay home to care for the children and he does little in the household chores. In June 2008, the Veteran was now sleeping 2-3 hours a night before waking up, sometimes in sweat although he cannot recall the dreams. He has ongoing feelings of anger and remained inside and isolated himself. He will go to Wal-Mart with his family but ends up leaving early because he does not like being around others. He reported still being easily frustrated with his two children and yelling at them at times. He grabs his daughter but does not hit his son. He has not destroyed furniture as before. His wife does most of the childrearing and house chores. He reported he was more comfortable with his financial situation with benefits from SSA. The Veteran still had a stoic like expression with monotone, short single word responses. He had a depressed mood and flat affect but his thoughts were concrete and logical. There were no disturbances or suicidal or homicidal ideations. In a statement submitted in June 2008, the Veteran reported being very temperamental with his wife and if his children cry, it reminds him of Iraq and he has to leave the room. He stated that his wife felt that his hygiene was unacceptable. Often times he would forget when he last performed hygiene-related activities, or just did not care to take care of himself in that manner. He forgets to perform small tasks and sometime finds he has not been paying attention to conversations. Alcohol is a problem. He does not feel particularly obligated to continue to interact with family, friends, or relatives and feels numb to others emotions and feelings. He experiences unprovoked outbursts of anger directed at his spouse and children and at times becomes violent. He has occasional suicidal thoughts and ideations which increase during times of stress. He has nightmares and wakes up startled or in a panic at times. The Veteran asserts the PTSD has affected his ability to look for and sustain gainful employment and his sleep problems affect his ability to work. When he worked he had unprovoked angry outbursts, lost his temper easily, and unable to cope with loud noises at work. He does not go into public buildings, shopping and it easily overwhelmed in social settings and easily gets angry with strangers. In February 2009, the Veteran underwent a VA PTSD examination. The examiner indicated that the claims file was unavailable for review. The Veteran related his family and military history to the examiner. He also commented on his daily routine, stating that he is essentially homebound on account of his irritability and temper. The Veteran stated that he drank six to seven beers a day. The VA examiner found that the Veteran did not meet the criteria for a diagnosis of PTSD. He stated that although the claims folder indicated the use of medication for PTSD, the Veteran had none of the sequela. The examiner provided an Axis I diagnosis of alcohol dependence and affective disorder, mixed, non-psychotic. A GAF score of 75 was assigned. The examiner also determined that the Veteran was capable of working, but that he was in potential need of vocational intervention. In March 2009, VA received statements from the Veteran's past employers. While one only confirmed the dates of employment, two indicated the Veteran was laid off due to a lack of work. However, one employer stated it employed the Veteran in January and February 2008 but the Veteran did not show up again after the last day worked. In October 2009, the Veteran underwent another VA examination to assess the severity of his PTSD. At the outset of the examination report, the examiner stated that the claims folder was not available for review. During the examination, the Veteran reported irritability and stated that he was easily angered. People and socializing were avoided. He stated that he felt on guard, especially at night. The examiner noted that the Veteran was oriented to person, place, and time, spoke clearly, and appeared to be calm and in good spirits. Suicidal and homicidal thoughts were denied. Hallucination and delusions were also denied. The examiner then stated that that the claims folder and previous VA examination reports were reviewed. The examiner rendered an Axis I diagnosis of depressive disorder and assigned a GAF score of 68. He found that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD, stating that the Veteran did not experience behavioral or social changes, or heightened physiological arousal due to service. The examiner then noted that the affective disorder that was diagnosed in the February 2009 VA examination was the same as the depressive disorder currently diagnosed. A VHA medical expert opinion was obtained in June 2013. The expert, a staff psychiatrist noted upfront that her assessment was limited because she had not evaluated the Veteran personally. Further, the Veteran used alcohol on a daily basis and because alcohol could contribute to many complaints such as sleep disturbance and rage, his alcohol use further confounds the diagnosis. Based on a review of the evidence, the expert concluded the Veteran has PTSD as opposed to other mental disorders such as a depressive disorder. The Veteran endorsed symptoms such as re-experiencing symptoms, avoidance behavior, and persistent symptoms of increased arousal. It is not clear to the expert, however, the degree those symptoms have contributed to the Veteran's inability to find or maintain employment. Some notes indicate improvement in his symptoms when employed and others indicated dissatisfaction with the type of job (apprentice construction worker) especially because it involved moving around to different jobs. The expert could not with confidence say that there is enough evidence to declare the Veteran unable to work or attribute his difficulties with finding and maintaining employment to PTSD when there are the other factors that are likely contributing to unemployment. The expert noted the most prominently documented issue appears to be anger and aggression which impairs, but does not necessarily preclude his ability to work. The expert attributed the anger issues more to a personality disorder and alcohol could also contribute to behavioral dishibition and anger outbursts as well. The expert also conceded there had been documented incidents of spousal and potential child physical abuse. The expert stated it is still unclear whether the incidents are primarily attributable to PTSD, substance abuse, or stress and dysfunction in the home environment. It is most likely some combination of all three. There is no anger leading to issues in the work environment. There is repeated documentation of depressive symptoms throughout the treatment. PTSD and depression are often co-morbid. As alcohol is a depressant, the expert stated it was impossible to adequately assess for the presence of a primary mood disorder in someone who has been actively abusing alcohol. The expert also discussed the GAF scores assigned to the Veteran and stated they are an unreliable and often arbitrarily assigned number with little clinical utility and poor inter-rater reliability. She estimated his average level of functioning to be approximately 50. The expert suspected a combination of PTSD, alcohol abuse, and possibly underlying personality pathology are responsible for his functional impairment. Nevertheless, while there was impairment in interpersonal and occupational functioning, he has demonstrated the ability to found employment when he so chooses. He was also noted to maintain some relationships with family and his few friends. Analysis In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). After a review of the record, the Board has determined that the overall effect of the PTSD constellation of symptoms more nearly approximates or equates to the criteria for a 70 percent rating due to occupational and social impairment with deficiencies in most areas, such as family relations, judgment, thinking, or mood. The Board also finds, however, that the schedular criteria for a 100 percent rating are not met and has not effectively resulted in total occupational and social impairment. The Veteran has problems with re-experiencing symptoms, avoidance symptoms, detachment/adhedonia, social interaction, and anger issues. While it appears the anger and social interaction issues cause the most problems, the avoidance or re-experiencing symptoms, detachment, and loss of interest while affecting his quality of life, do not appear to cause functional impairment. As to the anger and social interaction, the Veteran appears to be able to maintain employment if it is long term. A long term job apparently provides security to the Veteran and he avoids having to move to new, unfamiliar locations. Employment may even be a source of support for the Veteran since it reduces his financial worries, he has a strong work ethic, and his symptoms appear to improve with employment. The 70 percent rating recognizes that anger is a problem causing impairment in maintaining occupational function, but it is not as severe as the picture for a 100 percent rating. The Veteran may have impaired impulse control, but has the ability to use some judgment and walks off the job rather than continue an argument or confrontation. It is that adaptation, not inability to deal with stressful circumstances which the Board finds would more nearly approximate the criteria for a 70 percent rather than a 100 percent disability rating. Further, while the Veteran has quit jobs, there is no evidence that PTSD has resulted in him being fired from a job or received discipline/reprimands from his employer. This is another indication that the Veteran does not have total occupational impairment that would warrant a 100 percent rating. The Board finds that the medical evidence also supports the conclusion that the Veteran is not totally unemployable due to the disability at issue. As noted above, one expert found the Veteran had a strong work ethic and with intensive therapy on anger management, could be employed. The other stated that while PTSD was a factor, other, nonservice-connected factors also affected his employability and employment actually helped the Veteran to deal with PTSD. The medical experts thus have indicated that the Veteran wants to work and with therapy, the Veteran may be able to use coping strategies such as walking away instead of leaving the job altogether. While anger in the workplace is a problem, the Board finds it is a level of anger that more nearly approximates the criteria for a 70 percent, not 100 percent, rating. In short, the Board finds the Veteran's PTSD symptoms make employment difficult, but have not resulted in an inability to work. He has sleep difficulties with resulting symptoms, but again, the record before the Board demonstrates the severity does not affect his overall occupational functioning. It has caused the Veteran fatigue but apparently it has not occurred with a frequency or severity that he is still able to perform his job duties to his employer's satisfaction when working. While the Veteran suffers from depression, that symptom has not played a role in his occupational functioning, only his social functioning. The Veteran has had what he describes as suicidal thoughts, but has also stated he would never act upon them and his caregivers believe the Veteran's statements are not suicidal ideation. The record does not show that any of the other foregoing symptoms or any other symptoms of the same type and degree approximating a 100 degree rating. As previously noted, the Veteran was alert and oriented. He is able to care of his personal appearance although admittedly it is with the help of his wife, which the Board finds is the level of hygiene problems contemplated in the criteria for the 70 percent rating. Although he had some paranoid feelings such as watching his back, the symptoms did not interfere with his routine activities. Frequent complaints included sleep problems, social isolation, irritability, anger, memory impairment, and concentration difficulty, but the symptoms did not affect his ability to function independently albeit with some difficulty which again is the level of severity warranting a 70 percent rating. There is no objective evidence of obsessional rituals that interfere with routine activities, illogical or obscure speech, near continuous panic or depression affecting the ability to function independently and appropriately, or spatial disorientation. There is little or no evidence in the record of gross of impairment in communication; gross inappropriate behavior, disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The Veteran has demonstrated difficulty in adapting to stressful circumstances and has difficulty in to establishing and maintaining effective relationships, but for the reasons expressed above, the level of severity has not resulted in the higher level of severity mentioned in the criteria for a 100 percent rating. The Board also has no doubt that his PTSD affected his marriage and likewise is aware it has affected his relationship with his children but he is not estranged from any of them and it appears the wife offer supports even when he is not willing to accept interaction with her and their children. Although much of the GAF scores signify serious symptoms or serious impairment, the objective findings do not demonstrate that the Veteran's symptoms approximate the criteria for a 100 percent rating at any time considered in this appeal. From the effective date of the award of service connection on August 31, 2007, the pertinent record, which is primarily comprised of VA treatment records and VA examination reports, shows that the assigned GAF scores mostly ranged from 50 (indicating serious disability) to 60 or higher (indicating moderate disability). The scores have remained relatively static within the range of 50 to 60 throughout the period considered in this appeal. The VHA expert indicated an overall GAF score of 50 which indicates a serious disability, but not total occupational and social impairment, which was also consistent with the Veteran's symptomatology. In any event, a disability rating depends on evaluation of all the evidence and a VA examiner's classification of the level of a psychiatric impairment by words or by a GAF score is to be considered, but is not determinative of the percentage disability rating to be assigned. 38 C.F.R. § 4.126. As for symptoms associated with the diagnosis of PTSD but not listed in Diagnostic Code 9411, the symptomatology does not more nearly approximate or equate to the level of total occupation 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 ability 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. For example, the Veteran's sleep, memory, and concentration difficulties are not shown an inability to communicate, or persistent danger of hurting himself or others or disorientation to time or place; memory loss for names of close relatives, his own occupation, or name. The Veteran may have unprovoked irritability and anger that has manifested itself in his marriage and interaction with his children, but that is contemplated by the schedular criteria for a 70 percent rating. The Veteran also has been willing to use coping strategies such as letting his wife drive or handle the discipline of their children. As stated earlier, this demonstrates some, not an absence of, impulse control and judgment. The Board has considered that the symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan, 16 Vet. App. at 442. As such, the Board notes that the Veteran experiences other symptoms that are not listed in the criteria, but may reflect the severity of his PTSD. These include, but are not limited to difficulty sleeping, intrusive thoughts, reexperiencing, avoidance, and hyperarousal. Specifically, the Board has also considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with deficiencies in most areas, impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships due to such symptoms as: anxiety, avoidance, reexperincing the stressors, avoidance behaviors, and sleep impairment. As noted above, the Board finds that these symptoms, their level of severity, and effect do not represent a disability picture indicating a total impairment of social and occupational functioning. As for symptoms associated with the diagnosis of posttraumatic stress disorder but not listed in Diagnostic Code 9411, the symptomatology does not more nearly approximate or equate to the level of occupation and social impairment required for a 70 percent rating. Reconciling the various reports into a consistent disability picture, the present picture of the disability that emerges is that a material change in the overall severity of the disorder has not been demonstrated. At best, while there has been some fluctuation in the symptoms of PTSD, his symptoms have not reached a level of severity or more nearly approximate total occupational and social impairment. Instead, overall, the symptoms of PTSD, while serious, have resulted in a disability picture more consistent with occupational and social impairment with deficiencies in most areas. The symptoms that are attributable to posttraumatic stress under DSM- IV, such as anger, intrusive thoughts, anxiety, and social isolation or emotional distancing are not the equivalent to total occupational and social impairment that warrants a 100 percent rating. As noted earlier, the focus of the rating process is on industrial impairment and social impairment is significant only insofar as it affects earning capacity. There is no evidence demonstrating the Veteran's social impairment has totally affected his earning capacity as the medical evidence indicates the Veteran still has a prognosis for improvement if he receives intensive therapy for issues such as anger management. As discussed above, the symptoms and their severity have remained relatively stable. Although the Veteran has stated his symptoms have worsened, the Board notes that the Veteran's subjective complaints have remained essentially unchanged in severity, even with additional personal stressors in the Veteran's life such as financial dificulties, when detailed beyond the Veteran's characterizations. The Board finds that the PTSD disability has not significantly changed and that a uniform evaluation is warranted for the period considered under this appeal. Accordingly, as the degree of disability has not increased following the assignment of the initial rating a single evaluation, rather than "staged ratings" is proper. Fenderson, 12 Vet. App. at 126; see also Hart, 21 Vet. App. at 505. In short, in evaluating all the evidence, the Board finds that the VA examination reports and the VA treatment records reflect that the symptoms of PTSD are not so severe as to affect the Veteran's everyday life and his ability to function to a degree that more nearly approximates the schedular criteria for a 100 percent rating rather than that of a 70 percent rating. The symptomatology associated with the rating criteria under the General Rating Formula and symptomatology associated with the diagnosis of posttraumatic stress disorder under the DSM- IV do not more nearly approximate or equate to total occupational and social impairment required for the next higher rating. Although the evidence demonstrates that the Veteran has significant social impairment attributable to posttraumatic stress disorder, his symptomatology is not consistent with the criteria for a 100 percent disability rating under Diagnostic Code 9411. For these reasons, from August 31, 2007, the effective date of the award of service connection, the preponderance of the evidence is against an initial rating higher than 70 percent for PTSD, and the benefit-of-the-doubt standard of proof does not apply. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2013). Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2013) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for an extraschedular rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Comparing the Veteran's current disability levels and symptomatology to the Rating Schedule, the levels of disability are encompassed by the Rating Schedule. Higher ratings are provided for more severe conditions relating to PTSD. Furthermore, the Veteran has not been hospitalized for PTSD. While the Veteran has reported having missed some work on account of PTSD at issue, it does not appear to be significant beyond what it already accounted for in the schedular criteria. In light of the foregoing, the assigned schedule ratings are adequate and no referral to an extraschedular rating is required under 38 C.F.R. § 3.321(b)(1). In other words, the Board finds that the rating criteria reasonably describe the Veteran's PTSD disability and symptomatology, such as anger, social isolation, and emotional distancing, and these symptoms are contemplated by the Rating Schedule under Diagnostic Code 9411, and the Veteran does not have any symptomatology not already contemplated by the Rating Schedule. This is particularly so since the General Formula contemplates impairment levels with only examples of corresponding symptoms. Finally, the Board notes that an increased rating claim can also include a claim for total disability based upon individual unemployability (TDIU). See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In the Veteran's case, entitlement to TDIU was denied by the RO in December 2009. He did not appeal the decision and the record does not reflect a reasonably raised theory of entitlement for TDIU since that time. Thus, the Board will not further address the TDIU matter. ORDER Entitlement to an initial rating of 70 percent, but no higher, for PTSD is granted subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs