Citation Nr: 1338465 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 12-34 187 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an initial rating excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD H. Papavizas, Associate Counsel INTRODUCTION The Veteran had active military service from January 1968 to August 1969. This appeal to the Board of Veterans' Appeals (Board) arose from a November 2010 rating decision in which the Rating Officer (RO) implemented a September 2010 Board decision granting service connection for PTSD by assigning a rating of 30 percent for that disability. In February 2011, the Veteran submitted a notice of disagreement (NOD), in which he indicated that he had received psychiatric treatment at VA from 2010 to the present. The RO issued a statement of the case (SOC) in November 2012, and the Veteran filed a Form 9 to perfect his appeal in December 2012, along with additional statements. The RO issued a supplemental statement of the case (SSOC) in January 2013, in which the RO reconsidered the Veteran's claim in light of the more recent VA treatment records and continued the 30 percent rating for PTSD. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim on appeal have been accomplished. 2. For the entire appeal period, the Veteran's PTSD has been manifested primarily by depression, sleep impairments, nightmares, flashbacks, anxiety, and memory loss; collectively, these and other reported PTSD-related symptoms have resulted in occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks but satisfactory general functioning, at all points pertinent to this appeal. 3. The applicable schedular criteria are adequate to rate the disability under consideration at all points pertinent to this appeal. CONCLUSION OF LAW For the entire appeal period, the criteria for an initial rating in excess of 30 percent for PTSD have not been met at any time pertinent to this appeal. See 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION 1. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2013)), includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). When VA receives a complete or substantially complete application for benefits, VA must inform the claimant of any information and evidence not of record that (1) is necessary to substantiate the claim; (2) VA will seek to provide; and (3) the claimant is expected to provide. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). These notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-486 (2006). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). For initial rating claims, where, as here, entitlement to disability benefits has been granted and an initial rating has been assigned, the original claim has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for entitlement to benefits has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess, 19 Vet. App. at 490-491; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Nevertheless, the Board finds that the notification requirements of VCAA have been satisfied in this case. The Veteran was provided with proper VCAA notice in February 2007, prior to the initial unfavorable decision of the RO denying service connection for PTSD in January 2008. That letter advised the Veteran of what information and evidence would be needed to substantiate his service connection claim for PTSD, as well as what information and evidence should be submitted by the Veteran, and what information would be obtained by VA. The letter also afforded the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. Because the Veteran's service connection claim was substantiated when it was granted with an initial disability rating of 30 percent in 2010, no additional notice is needed. Under the VCAA, VA also has a duty to assist the claimant in the development of the claims by procuring pertinent records and in providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The record reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided and providing the Veteran with examinations. The Veteran requested in his 2011 NOD and 2012 Form 9 that VA obtain medical treatment records from the Fort Worth, Texas VA medical center, dating from September 2010 to present time. VA has acquired those records, as reflected by the claim file which includes the Veteran's service entry, treatment, and separation records; VA treatment records from January 2006 to June 2012; a March 2007 private medical opinion; and a December 2007 and October 2012 VA examination opinion. Additionally, the RO also provided the Veteran with VA examinations in December 2007 and October 2012, in which each examiner interviewed the Veteran; reviewed his claims file and medical records; considered his service history, psychiatric history, and social and occupational history; and offered a conclusion supported with a sufficient rationale. Because these examination reports are adequate and provide sufficient evidence to rate the Veteran's disability on a schedular and extra-schedular basis, VA fulfilled its duty to assist under VCAA. For these reasons, the Board finds that VA has fulfilled its notification and assistance duties under VCAA. 2. Increased Initial Rating Claim The Veteran argues that he should be assigned an initial rating greater than 30 percent for his service-connection PTSD. Generally, the Veteran has reported to VA outpatient treatment providers that he experiences depressed mood, anxiety, sleep issues, anger, irritability, flashbacks, and occasional difficulties with his wife and at work. Based upon the competent and credible evidence of record, the Board finds that the preponderance of the evidence weighs against an increase of his initial rating above 30 percent at all stages relevant to this appeal. A. Schedular Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and 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). However, where, as here, the question for consideration is entitlement to a higher initial rating, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged ratings" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran received a 30 percent rating for PTSD, effective December 19, 2006. He disagrees with this rating and claims that his disability is more severe than the designated rating of 30 percent. The Veteran's PTSD is currently evaluated under Diagnostic Code 9411 of the Rating Schedule. See 38 C.F.R. § 4.130. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, however it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Additionally, the symptoms listed in the Rating Schedule for mental disorders are not exhaustive but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan, 16 Vet. App. at 442. Nevertheless, all ratings in the Rating Schedule are associated with objectively observable symptomatology, and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms; a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Accordingly, the Board will consider both the specific symptomatology as well as the occupational and social impairment associated with the diagnostic code to determine whether an increased rating is warranted. The Board notes that the Veteran has been afforded diagnoses of psychiatric disorders other than PTSD, including major depression and anxiety disorder. In its analysis the Board has not attempted to dissociate any psychiatric symptoms from the service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998). Under the Rating Schedule, a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family 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); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions 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. It bears repeating that the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App at 442-443 (2002). Moreover, if the evidence shows that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. See Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Ultimately, the Court in Mauerhan upheld the Board's decision noting that the Board had considered all of the Veteran's psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. See Mauerhan, supra at 444. In addition to the criteria and principles reviewed thus far, the Board is guided by scores from Global Assessment of Functioning (GAF) tests often included in psychiatric examinations. GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Pertinent to this appeal, GAF scores from 61 to 70 reflect 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships, according to the DSM-IV. Scores from 51 to 60 are indicative of 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores from 31 to 40 indicate some impairment in reality testing or communication 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 was unable to work). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board briefly summarizes the evidence below. In September 2010, the Board established service connection for the Veteran's PTSD, and in November 2010, the RO awarded a disability rating of 30 percent for the Veteran's service-connected PTSD with an effective date of December 19, 2006. The date chosen for the award was based upon the date of the Veteran's original claim. The evidence of record includes numerous medical records for outpatient treatment and evaluation of the Veteran for his PTSD and his PTSD-related symptoms, approximately dating from December 2006 to October 2012. In 2006, the Veteran frequently met with VA medical professionals prior to and just after filing his service connection claim for PTSD in December 2006. In a February 2006 VA treatment record, the Veteran reported that his depressed mood of the past year, his stress at home and at work, and his arguments with his wife had all improved. He stated that he had experienced slight irritability and some forgetfulness and that he had withdrawn socially six months previously but felt better now. The examiner assigned the Veteran a GAF score of 60, screened him negatively for PTSD, and diagnosed him with adjustment disorder with depressed mood. In December 2006, the Veteran complained of increased anxiety and irritability, difficulty falling and staying asleep, problems with family and coworkers, social withdrawal, and lack of interest in sex. He denied any suicidal and homicidal ideation. The examiner found that the Veteran was neat, clean, and appropriately dressed; maintained good eye contact; had a mood that was depressed and anxious and an affect that was mood congruent; was goal-directed in his thoughts; showed no evidence of delusions or perceptual disturbances; had fair insight and good judgment; and demonstrated speech and psychomotor activity within normal limits. 2007 VA treatment reports reveal that the Veteran reported having thoughts of wanting to hurt people at work but no plan or intention to cause harm; getting "ticked off" by people easily; having nightmares and memories of Vietnam; feeling anger and irritability with his wife and coworkers; denying suicidal or homicidal thoughts; and doing better because of his sleep and mood medications. A private PTSD evaluation in March 2007 noted that the Veteran had severe flashbacks, nightmares, and extreme survivor's guilt; was very isolated and an extreme loner who never goes out; was "hooked" on alcohol and drugs; had lots of anger toward his wife; was hyper-vigilant and sensitive to noise; was very depressed; and felt that he could no longer live and thought about suicide but had no plans to act on those thoughts; and had significant memory problems. The private examiner assigned the Veteran a GAF score of 35/40. A December 2007 VA examination chronicled the Veteran's social, familial, and employment history. During that examination, the Veteran reported nightmares, night sweats, initial insomnia but regular nightly sleep of seven hours, depression, lack of motivation, vigilance, mistrust, anger, and arguments with his wife. The examiner found, among other things. that the Veteran's thought process was logical, coherent, and relevant; his affect blunted; his reasoning and judgment fair; his long term memory intact; and that his short-term memory and concentration issues were probably accounted for his lengthy history of substance use. The examiner also noted that the Veteran endorsed depressed mood that comes and goes and lasts up to a couple of days, denied any psychotic or manic symptoms, and reported passive suicidal and homicidal ideation. The Veteran received a GAF score of 60. The remaining medical records from 2008 to 2012 revealed that the Veteran denied any suicidal thoughts; regularly slept well despite his infrequent nightmares and night sweats; and continued to face issues with anger, irritability, and low mood; experienced some flashbacks. They also show improvement in the Veteran's mood, relations with his wife, and continued employment after his retirement. In May 2012, a VA examiner assigned him a GAF score of 68. Although all the evidence has been reviewed, the Board will discuss only the most relevant and salient evidence in its analysis below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Taking into careful consideration all pertinent evidence within the claims file, the Board concludes that the most appropriate disability rating is 30 percent for the Veteran's PTSD, which has been manifested chiefly by depression, sleep impairments, nightmares, flashbacks, anxiety, and memory loss. Under the Rating Schedule criteria, a 30 percent rating is justified where there is an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks with satisfactory general functioning with routine behavior, self-care, and conversation normal. In so concluding, the Board is guided by the criteria of the Rating Schedule, various other symptoms reported by the Veteran that fall outside of the Rating Schedule criteria, his GAF scores, and, ultimately, the impact of all of these factors on the Veteran's occupational and social impairment. As explained below, the pertinent evidence of record demonstrates that the Veteran suffers, at most, occasional social occupational deficits of a mild degree with mild symptomology. Preliminarily, the Board acknowledges the Veteran's contentions that his PTSD results in a level of impairment which warrants an increased disability rating. As a layperson, the Veteran is competent to report such observable symptomatology as his psychiatric symptoms. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Veteran's contentions regarding his PTSD symptomatology are considered generally credible, however the Board finds the Veteran's statements to be of lesser probative value as compared to the VA examination reports, rendered by objective examiners with expertise in assessing psychiatric impairment, which also include the Veteran's contemporaneously recorded comments about his disability. With respect to the March 30, 2007 private examination, the Board finds this medical opinion is not credible in its assessment of the severity of the Veteran's symptoms and their impact on his occupational and social functioning. In particular, the private examiner described the Veteran as an extreme loner who never goes out, is very depressed, feels as though he cannot live, and has lots of arguments with wife. In contrast, just two weeks prior on March 16, 2007, the VA examiner who treated the Veteran from January to October 2007 examined the Veteran who reported many of the same symptoms but stated that he was doing better with the medication, asserted that his mood was better, denied any suicidal or homicidal ideation, and admitted only that he was angry and irritable with his wife and coworkers. The Veteran's medication was not increased at this time. Subsequent reports concerning the Veteran's symptomatology from the same VA examiner in 2007 are to the same effect. From this disparity, the Board concludes that the private examiner's opinion is inaccurate in its characterization of the Veteran's symptoms and occupational and social functioning and therefore discredits those characterizations. The most persuasive evidence supporting a continued disability rating of 30 percent is the Veteran's work and family and social circumstances, which strongly indicate satisfactory general social and occupational functioning indicative of a 30 percent rating. Upon separation, the Veteran held a succession of jobs for less than a year each and experienced difficulty getting along with coworkers. See December 2007 VA examination. However, beginning in the 1970s he secured steady, full-time employment as a truck driver until his retirement in September 2007 from his last job of 18 years. Id. Over the course of his truck-driving career, he worked for about five or six companies, changing jobs when the companies he worked for went out of business, and he denied missing significant amounts of work due to mental illness. Id. After retiring, he continued to work as a part-time school bus driver and operated his own lawn care business. See December 2007 and October 2012 VA examinations. Still, over six years of psychiatric treatment, the Veteran disclosed some interpersonal work difficulties: personality conflicts, which had improved over time; difficulty getting along with coworkers; and getting "ticked off" by people and getting into verbal disagreements. February 2006, December 2006, and June 2007 VA treatment records. In addition, the Veteran once claimed that he had a part-time job as a school bus driver "but could not do it because he was too anxious and irritable." February 2011 VA treatment record. However, the record shows that he continued to work as a part time school driver before and after this complaint. See February 2012, June 2012 VA treatment records; December 2007, October 2012 VA examination records. Moreover, the Veteran has denied any conflicts or problems with work, affirmed that working helps elevate his mood, admitted that he likes to stay busy even though driving a school bus can be very stressful, and asserted that he enjoyed driving a school bus. See August 2009, September 2010, September 2011, and June 2012 VA treatment records. Despite the Veteran's sporadic complaints about work, the Board finds that his lengthy work history demonstrates a high degree of occupational functioning. The Veteran worked full time for nearly two decades until his retirement in 2007. During that time, he worked only for a few employers and sought new employment when his employers went out of business. After his retirement, he worked part time as a school bus driver and opened his own lawn care business. He has stated that prefers to stay busy with work and work elevates his mood. Furthermore, the record lacks any evidence of disciplinary measures taken against or termination of the Veteran due to workplace maladjustment. Against this backdrop, the Veteran's sparse reported occupational deficits, which are best described as mild, demonstrate only occupation impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In addition to a successful work life, the Veteran has a successful social and family life. The Veteran has been married for about 40 years to his current wife, and he has one adult daughter and two grandchildren. See December 2007 VA examination. The Veteran is on good terms with all of them, and he enjoys spending time with his grandchildren for leisure and recreation. Id. Initially, in a February 2006 VA treatment record, he stated that he and his wife were experiencing problems with frequent arguing six months prior, however he explained that they resolved those problems and were more supportive of each other. Despite his good family relations, the Veteran once complained that he had some family difficulty, and stated that he felt angry and irritable toward his wife. December 2006 and March 2007 VA treatment records. However, in a January 2007 treatment record, the examiner noted that the Veteran has a "supportive family or other relationship," and the Veteran explained that although he and his wife argued a lot for the past four to five years, they "get along okay but argue off and on." Subsequent VA treatment records indicate that the Veteran is happily married, reports having a good relationship with his wife, receives good support from his family, enjoys spending time with his adult daughter and grandchildren, that he gets along well with them, and that his family is doing well. See May 2009, August 2009, February 2010, September 2010, December 2010, June 2011, February 2012, and June 2012 VA treatment records. Moreover, the Veteran enjoys basketball, working on guns, visiting his family, going to movies, and occasionally seeing friends. December 2007, October 2012 VA examinations. Altogether, the Board finds on this record that the Veteran experiences occasional, mild relational difficulties with his wife but that he is nevertheless able to sustain positive relationships with her and others which demonstrate high social functioning. In addition, the Veteran's symptomatology, as shown from VA treatment records from 2006 to 2012 and VA examinations in December 2007 and October 2012, also justifies a continued rating of 30 percent. This evidence shows that the Veteran's PTSD is manifested by depressed mood, low motivation, anxiety, irritability, difficulty falling and staying asleep, social withdrawal, flashbacks, anger, possible short term memory issues, occasional alcohol use or abuse, nightmares and hypnogogic hallucinations, low energy, agitation, intrusive thoughts, and hyper-vigilance. In particular, the Veteran's mood and sleep impairment have been managed with medication, and the Veteran himself frequently conveyed improvement in his mood. The Board finds that, at all times relevant to this appeal, the frequency, degree of severity, and duration of these symptoms - including those listed and not listed in the Rating Schedule criteria - result in occupational and social impairment of no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. As explained above, the Veteran, despite the challenges presented by his disability, has maintained positive familial and social relationships, sustained a successful career as a truck driver for over eighteen years, and continues to pursue and secure steady employment as a school bus driver. In addition to consideration of the above symptoms and criteria, the Veteran's GAF scores play a role in the Board's determination. His GAF scores from VA treatment and examination records are as follows: 60 in February 2006, 60 in December 2007, 45 in May 2010, 50 in September 2010, and 68 in October 2012. A private treatment record in March 2007 reflected a GAF score of 35/40. The Board does not credit the GAF score of 35/40, as it appears to be based upon inaccurate, exaggerated, and discredited characterizations of the Veteran's symptomology by the private examiner. Likewise, the Board discredits the GAF score of 45 by a VA examiner in May 2010 because the VA examiner did not explain the basis for that score and it conflicts strongly with the other positive findings within the report showing the Veteran's low risk of mental instability and positive social and therapeutic factors. The VA examiner's assignment of a GAF score of 50 in September 2010 may be explained by the Veteran's report of having suicidal thoughts nine months prior. However, because the record demonstrates the Veteran's near uniform denial of suicidal ideation, the Board concludes that the GAF score of 50 is anomalous and inaccurate as the record fails to demonstrate that the Veteran has serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Instead, the Board finds the GAF scores of 60 and 68 highly persuasive as they accurately convey the Veteran's mild to moderate impairment of social and occupational functioning. While GAF scores are not determinative in and of themselves, the Board finds the Veteran's GAF scores here to be highly probative when taken together with the evidence of mild symptomatology and effective occupational and social functioning. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Taken together, the Veteran's symptoms and his GAF scores depict a state or situation of mild occupational and social impairment meriting a continued initial rating of 30 percent. The Board further finds that assignment of a rating greater than 30 percent here is inappropriate. The evidence does not show that the Veteran experienced symptoms or symptoms of the kind that indicate the level of occupational and social impairment associated with a 50 percent rating. The record establishes that the Veteran's speech is normal and that his judgment is good. There is no evidence of panic attacks, difficulty understanding complex commands, or impaired abstract thinking. Although once characterized as blunted, the Veteran's affect is consistently described as full range and appropriate in the record. The Veteran has infrequently reported forgetfulness and short term memory impairment, but VA examiners did not find his short term memory to be impaired and noted that his long term memory was intact. Although the Veteran has communicated at times that he has felt down, very depressed, anxious, and claimed low motivation and energy, the record shows that his depressed mood comes and goes, his depression is mild and not severe, his mood is often reported as good or improved, he feels no sadness, and he has experienced increases in energy and motivation. Additionally, the Veteran has recounted arguing with his wife and experiencing some difficulty with family and coworkers, however the credible evidence of record demonstrates that he is happily married to his wife, has good family support, has a close relationship with his adult daughter and his two grandchildren, and has a long and successful track record with work. Despite his reported difficulties, the Veteran has consistently been able to function well occupationally and socially as demonstrated by his strong familial relationships and his successful work history. Accordingly, the Veteran's PTSD and PTSD-related symptoms do not rise to the level of occupational and social impairment with reduced reliability and productivity warranting a 50 percent rating. Similarly, the Board finds that an increase to a rating for 70 percent is not warranted. The record fails to show any obsessional rituals which interfere with routine activities, impaired impulse control, or spatial disorientation. The Veteran's speech is normal, and his appearance and hygiene have always been appropriate. While it is true that the Veteran has experienced anxiety (but not panic or panic attacks) and depression, there is no indication that these symptoms have adversely affected his ability to function independently, appropriately, and effectively. Moreover, as discussed above, the Veteran has adapted well to the stress of work and has been consistently capable of establishing and maintaining effective relationships with others, especially close family members. Although the Veteran admitted once in September 2010 to having suicidal thoughts nine months before, the examiner concluded during that psychiatric visit that the Veteran's risk of suicide was low, and the other evidence of record strongly and consistently shows that the Veteran otherwise denied any suicidal ideation. Because neither these nor other symptoms suffered by the Veteran demonstrate occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, a rating increase to 70 percent is improper. Likewise, the Board finds that there is no evidence supporting an increase to a rating of 100 percent because there is no evidence of 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. Moreover, the other symptoms reported by the Veteran have resulted in at most mild, not gross, social and occupation impairment, and the pertinent evidence of record of the Veteran's positive social relationships and regular employment do not indicate total impairment. B. Extra-schedular Rating The VA Rating Schedule will apply unless there are exceptional or unusual factors, which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Under those circumstances, where the schedular evaluations are found to be inadequate, a veteran may be awarded a rating higher than that encompassed by the schedular criteria. 38 C.F.R. § 3.321(b)(1). According to the regulation, an extra-schedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. Id. There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher, 4 Vet. App. at 60. See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). See also Thun, supra. If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. See Thun, supra. Considering the pertinent evidence of record in light of the above, the Board finds a higher initial rating on an extra-schedular basis is not warranted for the Veteran's PTSD at any point pertinent to his claim. The Rating Schedule criteria for Diagnostic Code 9411 contemplate the PTSD symptoms complained of by the Veteran. Moreover, the Rating Schedule allows for consideration of non-schedular symptoms and the Veteran's GAF scores. The Board has assessed the Veteran's symptomology and GAF scores to assess their impact on the Veteran's social and occupational functioning in concluding that a continued 30 percent rating for his PTSD is appropriate. An increased rating above 30 percent is available, but, as explained above, the Veteran does not meet the criteria for a higher rating. Because the Rating Schedule criteria reasonably describe the Veteran's disability level and symptomatology, the Board need not make any extra-schedular determination in this case. See VAOGCPREC 6-96 (Aug. 16, 1996). See also Thun, supra. Accordingly, referral for consideration of an extra-schedular rating is not required. C. TDIU Finally, the Board notes that every claim for a higher rating includes a claim for a total rating based on individual unemployability (TDIU) where a Veteran claims that his service-connected disability prevents him from working. See Rice v. Shinseki, 22 Vet. App. 447 (209). Here, the Veteran implied once in February 2011 that he had left his part-time job as a school bus driver because he was anxious and irritable. However, outside of this single anomalous entry, which the Board assigns very low probative value, the record shows that the Veteran has consistently worked on a full-time basis as a truck driver until his retirement in 2007 and afterward as a part-time school bus driver and in his own law care business. In a September 2011 VA treatment record, the Veteran admitted that he was working as a part time school bus driver, maintaining that it was very stressful for him but that he likes staying busy. Later medical records establish that the Veteran continued to employment as a part time school bus driver. See February 2012, June 2012 VA treatment records; October 2012 VA examination record. Furthermore, the Veteran has asserted that he likes to keep busy with work, that work elevates his mood, and he has denied any conflicts or problems with work. See August 2009, September 2010, and September 2011 VA treatment records. Given the Veteran's history of steady employment and his positive statements about work and its positive effect on his disability, which the Board finds highly probative, the Board finds that Rice is inapplicable to the facts of this case because the Veteran has not shown himself to be unemployable. For all of the foregoing reasons, the Board finds that there is no basis for an initial rating for PTSD above 30 percent, and that the claim for a higher initial rating must be denied. In so concluding, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher initial rating for PTSD at any point pertinent to this appeal, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Therefore, the Board rules that a continuation of an initial rating of 30 percent on the Veteran's PTSD is appropriate at all points pertinent to this appeal. ORDER The Veteran's request of an initial rating in excess of 30 percent is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs