Citation Nr: 1338506 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 07-21 173 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an effective date prior to March 14, 2005, for the grant of service connection for an acquired psychiatric disorder, manifested by posttraumatic stress disorder (PTSD), major depressive disorder (MDD) and anxiety, also associated with asbestosis. 2. Entitlement to an initial disability rating in excess of 70 percent for PTSD with MDD and anxiety, also associated with asbestosis (hereinafter PTSD). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD K.A. Kennerly, Counsel INTRODUCTION The Veteran served on active duty from April 1962 to March 1966. Procedural History This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Winston-Salem, North Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA), dated in October 2005 and June 2007. The Veteran initiated his original claim of entitlement to service connection for PTSD in March 2005. The October 2005 rating decision denied this claim. The Veteran submitted his notice of disagreement (NOD) with this determination in March 2006, and timely perfected his appeal in July 2007. The June 2007 rating decision granted entitlement to service connection for MDD, assigning a 30 percent disability rating, effective from May 21, 2007. The Veteran submitted an NOD with the assignment of the 30 percent disability rating, as well as the effective date. He timely perfected his appeal in June 2008. In March 2011, the Board remanded these issues to the Appeals Management Center (AMC) for additional evidentiary development. Subsequently, a rating decision was issued in April 2012, granting entitlement to service connection for PTSD and recharacterized the service-connected disability as PTSD with MDD and anxiety, associated with asbestosis. The Veteran was assigned a 70 percent disability rating, effective from March 14, 2005. Since this award and increase did not constitute a full grant of the benefits sought, the issues remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 39 (1993). Personal Hearing The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2013). The Veteran has been accorded the opportunity to present evidence and argument in support of the claims. On both his July 2007 and June 2008 substantive appeals [VA Form 9] he declined the option of testifying at a personal hearing. Employability Additionally, the Board notes that the United States Court of Appeals for Veterans Claims (Court) held in Rice v. Shinseki, 22 Vet. App. 447 (2009) that every claim for a higher evaluation includes a claim for a total rating based on individual unemployability (TDIU) where the Veteran claims that his service-connected disabilities prevent him from working. The Board notes that the Veteran retired from the United States Postal Service in 2008, due to the completion of his career. See VA Examination Report, April 9, 2011. Moreover, the Veteran did not specifically indicate that he is currently unemployed or completely unemployable as result of his service-connected psychiatric disability. As such, the Board finds that Rice is not applicable to the current appeal. There must be evidence of unemployability in the record. See Rice, 22 Vet. App. 447, citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). Thus, any further discussion of an issue of entitlement to TDIU is not necessary. See Rice, supra. FINDINGS OF FACT 1. A claim of entitlement to service connection for PTSD was received by VA on March 14, 2005. 2. No communication or evidence was received prior to March 14, 2005, which could be interpreted as an informal or formal claim of entitlement to service connection for an acquired psychiatric disorder. 4. The Veteran's PTSD has not resulted in 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. 5. The evidence does not show that the Veteran's PTSD is so exceptional or unusual that referral for extraschedular consideration by designated authority is required. CONCLUSIONS OF LAW 1. The criteria for an assignment of an effective date prior to March 14, 2005, for the award of service connection for an acquired psychiatric disorder have not been met. 38 U.S.C.A. §§ 5101(a), 5110 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.151, 3.155, 3.156, 3.157, 3.400, 20.201 (2013). 2. The criteria for a disability evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2013). 3. Application of extraschedular provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. The Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims of entitlement to an initial disability rating in excess of 70 percent for PTSD and entitlement to an earlier effective date, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). As to the claim for an initial evaluation in excess of 70 percent for PTSD, as service connection, an initial rating, and an effective date have been assigned during the appeal, the notice requirements of 38 U.S.C.A. § 5103(a), have been met. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The same conclusion applies to the claim for an earlier effective date for the award of service connection for PTSD, as this benefit was awarded, and the Veteran has now appealed the effective date assigned. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. The Veteran submitted a February letter from a medical professional from the Goldsboro Psychiatric Clinic. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. In addition to the paper claims file, the Board has also reviewed all the evidence in the Veteran's Virtual VA and Veterans Benefits Management System electronic claims files. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). The RO provided the Veteran with VA examinations in connection with his claim for increase in July 2008 and April 2011 (the May 2007 VA examination was provided in connection with the Veteran's claim for entitlement to service connection for a psychiatric disorder). There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected psychiatric disability since he was last examined. See 38 C.F.R. § 3.327(a) (2013). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95. The April 2011 VA examination report is thorough and supported by VA outpatient treatment records. The examination in this case is adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). VA did not provide the Veteran with an examination in connection with the claim involving an earlier effective date, as it does not meet the statutory requirements for entitlement to a VA examination or medical opinion. See 38 U.S.C.A. § 5103A(d)(2)(A)-(C) (West 2002); see also 38 C.F.R. § 3.159(c)(4)(A)-(C) (2012). Regardless, oftentimes in claims involving earlier effective dates, the evidence necessary to determine whether an earlier effective date is warranted is already in the claims file. This is the situation here. Additionally, the Board finds there has been substantial compliance with its March 2011 remand directives. The Board notes that the Court has held that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand.). The record indicates that the AMC scheduled the Veteran for a medical examination and the Veteran attended that examination. The AMC later issued a rating decision and an SSOC. Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the Veteran the right to compliance with its remand orders). Therefore, in light of the foregoing, the Board will proceed to review and decide the claim based on the evidence that is of record consistent with 38 C.F.R. § 3.655 (2013). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Importantly, the Board notes that the Veteran is represented in this appeal. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has submitted argument and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. II. The Merits of the Claims A. Earlier Effective Date Based upon a complete review of the evidence on file, and for the reasons and bases expressed below, the Board finds that the currently assigned effective date of March 14, 2005, is the earliest effective date assignable for service connection for an acquired psychiatric disorder. Governing Law and Regulations The effective date for a grant of service connection is the day following the date of separation from active service or the date entitlement arose, if the claim is received within one year after separation from service. Otherwise, it is the date of receipt of claim. 38 U.S.C.A. § 5110(a), (b); 38 C.F.R. § 3.400(b)(2)(i). The provisions of 38 U.S.C.A. § 5101(a) mandate that a claim must be filed in order for any type of benefit to be paid. Jones v. West, 136 F.3d 1296, 1299 (Fed. Cir. 1998). A "claim" includes a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). A formal claim is a specific claim in the form prescribed by the Secretary. 38 C.F.R. § 3.151. Also, any communication or action indicating the intent to apply for a benefit under the laws administered by the VA may be considered an informal claim, provided that it identifies generally, although not necessarily with specificity, the benefit sought. 38 C.F.R. § 3.155. The United States Court of Appeals for the Federal Circuit has emphasized VA has a duty to fully and sympathetically develop a Veteran's claim to its optimum. See Hodge v. West, 155 F.3d 1356, 1362 (Fed. Cir. 1998). This duty requires VA to "determine all potential claims raised by the evidence, applying all relevant laws and regulations," Roberson v. West, 251 F.3d 1378, 1384 (Fed. Cir. 2001), and extends to giving a sympathetic reading to all pro se pleadings of record. See Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). Discussion The Board has carefully reviewed the record and can identify no communication from the Veteran, which may reasonably be considered a claim of entitlement to service connection for an acquired psychiatric disorder prior to the claim received on March 14, 2005, even based upon a liberal construction. The Board has reviewed the evidence in the record prior to his informal claim for service connection for PTSD and cannot find evidence of an intent to file a claim for service connection for PTSD or any psychiatric disorder. For example, in the Veteran's original claim for service connection, submitted in August 1973, he indicated he was seeking benefits solely for a "[b]roken wrist." See VA Form 21-526, Veteran's Application for Compensation or Pension, at item # 25. There was no mention of a psychiatric disorder in the application for benefits. The Veteran next filed a VA Form 21-526 on July 22, 1991. There, he was seeking service connection for exposure to asbestos only. See item # 24. There was no mention of a psychiatric disorder in the application for benefits. The Veteran submitted other statements in connection with this claim in the early 1990s (the RO had denied the claim and the Veteran appealed the denial). There was no mention of a psychiatric disorder in these submissions. In July 2001, VA received a facsimile from the Veteran asking VA to send him a copy of his service treatment records, as he needed them for a position with the Post Office. There was no mention of a psychiatric disorder. The next time the Veteran contacted VA was on March 14, 2005, when he submitted an informal claim for service connection for PTSD. This is the first time the Veteran expressed an intent to file a claim for service connection for a psychiatric disorder. Though the Veteran contends that the effective date for his award should be immediately after his discharge from service, it is clear that at no time prior to the March 14, 2005, claim, did he submit a claim for service connection for a psychiatric disorder. March 14, 2005, is the proper effective date. The Board is aware that when the Veteran submitted his claim for entitlement to service connection for PTSD, he attached a February 2005 letter from a medical professional, who diagnosed the Veteran with PTSD. This does not provide a basis to grant an effective date going back to February 2005, as the statute says that service connection cannot be awarded prior to the date of claim. 38 U.S.C.A. § 5110. Additionally, the provisions of § 3.157(b) would not apply, as such regulation applies only to a distinct group of claims where service connection has already been established for the relevant disability. See LaLonde v. West, 12 Vet. App. 377, 382 (1999) (where appellant had not been granted service connection, mere receipt of medical records could not be construed as informal claim). To some extent, the Veteran appears to be raising an argument couched in equity, in that he contends that he evidenced psychiatric disability long before he filed his claim, and he should be compensated therefore. However, the Board is bound by the law and is without authority to grant benefits on an equitable basis. See 38 U.S.C.A. §§ 503, 7104 (West 2002); see also Harvey v. Brown, 6 Vet. App. 416, 425 (1994). The Board has decided this case based on its application of this law to the pertinent facts. Conclusion In summary, based on the evidence of record, the Board finds the preponderance of the evidence is against the claim of entitlement to an effective date prior to March 14, 2005, for the grant of service connection for PTSD. The benefit sought on appeal is accordingly denied. B. Increased Rating Claim The Veteran contends that he is entitled to an initial disability rating in excess of 70 percent for his acquired psychiatric disorder. Governing Law and Regulations Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. See 38 C.F.R. § 4.10 (2013). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. See 38 C.F.R. §§ 4.1, 4.2 (2013); see also Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. See 38 C.F.R. § 4.7 (2013). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. See 38 C.F.R. § 4.21 (2013). This appeal arises from the rating decision in which service connection was established for an acquired psychiatric disorder. As such, the Board has considered whether different ratings for different periods of time are warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). Criteria for rating mental disorders are found in the General Rating Formula for Mental Disorders, at 38 C.F.R. § 4.130. According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the individual's capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126(a) (2013). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. See 38 C.F.R. § 4.126(b) (2013). A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130 (2013). A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. That portion of VA's Schedule for Rating Disabilities (rating schedule) that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). See 38 C.F.R. § 4.130 (2013). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. GAF scores ranging between 61 and 70 are assigned when there are 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 when the individual is functioning pretty well and has some meaningful interpersonal relationships. See DSM IV. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when there are 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). Id. GAF scores ranging between 31 and 40 are assigned when there is 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). Id. Discussion The only question before the Board in evaluating the severity of the Veteran's disability is whether his PTSD is so severe as to cause total occupational and social impairment warranting a 100 percent schedular rating. After review of the evidence of record, the Board finds that the Veteran's psychiatric symptomatology does not manifest in total occupational and social impairment. Private treatment records dated in February 2005 indicate that the Veteran suffered from nightmares since approximately 1990, which occurred two to three times per week. He noted that he experienced flashbacks, startled easily and felt depressed most of the time. The Veteran indicated that his recent memory was severely impaired, noting that he could not remember what he read and became lost when traveling. He also endorsed seeing some shadowy hallucinations out of the corner of his eye. Conversely, the Veteran also reported that he had been married for 36 years, was employed and socialized frequently. Dr. E.W.H., M.D. stated that "because of this service connected PTSD, [the Veteran] is moderately compromised in his ability to sustain work relationships." The Veteran was assigned a GAF score of 45, indicating 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). See Private Treatment Record, E.W.H., M.D., February 6, 2005. The Veteran was afforded a VA PTSD examination in May 2007. During his mental status examination, the Veteran was noted to be fatigued and tense, his affect was constricted, his mood was depressed, he was easily distracted and he suffered from sleep impairment. The Veteran also endorsed markedly diminished interest or participation in significant activities, restricted range of affect (e.g., unable to have loving feelings), irritability or outbursts or anger, difficulty concentrating and hypervigilance. Conversely, he was appropriately dressed, his speech was spontaneous and coherent, his attitude was cooperative and attentive though guarded, he was oriented to person, place and time, his thought process and content were unremarkable, he did not experience suicidal or homicidal ideation, had no problems with activities of daily living and had good insight into his problems. The Veteran reported that he was married with two adult children and maintained good relationships with his wife, children and grandchildren. He also noted that he was a member of the American Legion and Veterans of Foreign Wars (VFW) and attended church. His hobbies included building things in his garage. The VA examiner assigned the Veteran a GAF score of 54, indicating moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). See VA PTSD Examination Report, May 21, 2007. The Veteran was afforded a second VA PTSD examination in July 2008. At that time, he was noted to have a sarcastic attitude, constricted affect and dysphoric mood. The Veteran reported that his mind often wandered, which particularly affected his ability to read and retain what he read. He continued to complain of sleep impairment, reporting five to six hours of sleep per night, waking three to four times during that time. The Veteran reported strongly disliking people being behind him, even while driving. He endorsed recurrent and intrusive distressing recollections, including images, thoughts or perceptions. He also noted feelings of detachment or estrangement from others. See VA PTSD Examination Report, July 2, 2008. Notably however, at the time of the VA examination, the Veteran was clean, neatly groomed and appropriately dressed. His speech and psychomotor activity were unremarkable, he was oriented to person, place and time, his thought process was unremarkable, there was no evidence of obsessive or ritualistic behavior, panic attacks, homicidal or suicidal ideation or hallucinations. His remote memory was considered normal and his recent and immediate memory were only considered mildly impaired. He continued to report having a happy marriage and good relationships with his adult daughters, who he saw daily. He reported having few friends and being a non-active member of the VFW and American Legion. He again noted that he enjoyed working in his garage and building things. He also indicated that he only saw his private psychiatric physician one to two times per year. Id. Finally, the VA examiner stated that disturbances did not cause clinically significant distress or impairment in social, occupational or other important areas of functioning in the Veteran. Further, it was noted that with continued medication management, the Veteran could continue to have improvement in his symptoms. The VA examiner also specifically noted that the Veteran did not experience: total occupational and social impairment, resulting in deficiencies in judgment, thinking, family relations, work, mood or school; reduced reliability and productivity due to PTSD symptoms; or occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning. Ultimately, he was assigned a GAF score of 58, which, as noted above, is assigned when there are moderate symptoms or moderate difficulty in social, occupational, or school functioning. Id. The Board is aware of the Veteran's argument that the July 2008 VA examiner was not licensed until September 2008, which raised "professional issues." It was further argued that the VA Medical Center psychologist internship program is predoctoral, and thus, the July 2008 VA examiner "may not even have had her doctorate at the time of the examination." See Written Brief Presentation, February 8, 2011. The Board does not find this argument to be persuasive evidence of the July 2008 VA examination's inadequacy. Initially, the Board notes that at the time of the July 2008 VA examination, the examiner had already been awarded her Ph.D., as indicated in her signature block on the examination report. Further, a July 3, 2008, addendum noted that the VA examiner received at least weekly supervision with the co-signing physician, who noted "this case and patient visit have been reviewed and discussed. This clinician concurs re: the assessment and treatment plan for the veteran." See VA Examination Addendum, July 3, 2008. As such, the Board finds Veteran's argument to have little merit. Finally, the Veteran was afforded a third VA PTSD examination in April 2011. At that time, the Veteran reported generally avoiding others. He endorsed having a short fuse and getting into arguments easily, but did not have any legal problems. He was often sarcastic with considerable negative feelings toward "the system" due to his prior denial of benefits. He reported being depressed much of the time and self-isolated. Specifically, he reported being frequently anxious about developing pulmonary disease from his asbestos exposure and had frequent pessimistic thoughts that it is only a matter of time until this disease kills him. The Veteran stated that he avoided potential trigger situations and claimed that he felt numb in general. He also endorsed persistent symptoms of increased arousal, but noted that the duration of these experiences was somewhat under his control and "last as long as I want." He stated that he experienced irritability on a daily basis that varied from mild to severe, depending on the situation. See VA PTSD Examination Report, April 9, 2011. Conversely, the Veteran was noted to be generally pleasant and cooperative. His speech was normal, his affect was full, he was oriented to person, place and time, he demonstrated good judgment and insight and did not endorse homicidal or suicidal ideation. He also demonstrated a good memory. The Veteran again stated that he was happily married and had an excellent relationship with his children. The VA examiner assigned a GAF score of 48, indicative of serious symptoms or serious impairment in social, occupational, or school functioning. Ultimately, the VA examiner concluded that the Veteran did not suffer from total occupational and social impairment, though his PTSD symptoms did result in deficiencies in judgment, thinking, family relationships, work, mood or school. Id. As clearly demonstrated by the evidence above, to include the Veteran's statements, the record does not demonstrate that the Veteran meets the criteria for a 100 percent disability rating. While the Board is certainly aware that the criteria listed in 38 C.F.R. § 4.130 are not exhaustive, the Veteran fails to meet any of the level of severity of the symptoms under the 100 percent rating. Specifically, at no time did the Veteran demonstrate gross impairment in thought process or communication. In fact, during each of the aforementioned examinations (both private and VA), the Veteran was noted to have a clear thought process and was able to communicate clearly. He also repeatedly indicated that he had a happy marriage for many years and had an excellent relationship with his adult children and grandchildren. The November 2011 examiner made a finding that there was no inappropriate behavior. Though the Veteran has noted that he experienced some "shadowy hallucinations out of the corner of the eye" during his February 2005 private examination, in each of the subsequent VA examinations, the Veteran consistently denied experiencing any hallucinations. Similarly, there is no evidence of record to establish that the Veteran has ever demonstrated grossly inappropriate behavior or was in persistent danger of hurting himself or others. He is clearly able to perform activities of daily living. In fact, he repeatedly indicated that he enjoyed building things in his garage. Such symptoms refute a finding that the Veteran is totally socially and occupationally impaired. Though the Veteran has endorsed some memory loss, this was considered to be minimal by the VA examiners. The November 2011 examiner found that the Veteran's remote, recent and immediate memory were all "good." In other words, there is no evidence of the Veteran's memory being so deficient that he does not remember his own name or those of his relatives, including his wife and children. At the time of the February 2005 examination, Dr. H stated that the Veteran was "moderately compromised" by his PTSD symptoms. Such description is not indicative of the level of severity of the symptoms contemplated by the 100 percent rating. The Board is aware that the February 2005 examiner assigned a GAF score of 45, which contemplates more severe symptoms than the examiner described in the letter. The examiner did not explain why he assigned score, which score contemplates being "unable to keep a job." However, Dr. H made a finding that the Veteran's PTSD "moderately compromised" his ability to sustain work relationships. The Board accords more probative value to the clinical findings made in that record than the cursory assignment of a GAF score without an explanation. Regardless, the criteria described under that GAF score are similar to the level of severity contemplated by the 70 percent rating. Dr. H made no finding that the Veteran was "unable to keep a job." In assigning a GAF score of 48, the November 2011 VA examiner made a specific finding that the Veteran was not totally socially and occupationally impaired. In viewing the totality of the evidence, the Veteran is clearly not entitled to a 100 percent disability rating for his psychiatric disability. In not granting a 100 percent schedular rating for his psychiatric disability, the Board is not minimizing the severity of the Veteran's symptoms. These symptoms, while productive of impairment, are not so severe that the Veteran can be said to be totally impaired. As discussed above, while the Veteran may have difficulty establishing and maintaining relationships with others, the evidence does not demonstrate total social and occupational impairment. As such, a 100 percent disability rating may not be assigned. See 38 C.F.R. § 4.130 (2013). Conclusion For the reasons stated above, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's PTSD approximates the criteria for a 100 percent disability evaluation. There is no reasonable doubt to be resolved in this case. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). C. Extraschedular Consideration Also considered by the Board is whether referral is warranted for a rating outside of the rating schedule. To accord justice in an exceptional case where the schedular standards are found to be inadequate, a claim may be referred to the Director of the Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. See 38 C.F.R. § 3.321(b)(1) (2013). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. See 38 C.F.R. § 3.321(b) (2013). Extraschedular consideration involves a three step analysis. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. Here, all symptoms of the Veteran's PTSD are contemplated by the schedular criteria. The criteria provide examples of the types and degrees of symptoms for each level of compensation and the Veteran's symptoms do not deviate from those types of symptoms or from the severity of symptoms. Essentially, he has reported anxiety, depression, memory problems and difficulty in relationships, and has been found to have deficits in memory and concentration. All of these symptoms are consistent with those listed in the schedular criteria. As to the severity of the symptoms, the schedular criteria contemplate disability presenting a danger to oneself or others, memory problems to the extent of not knowing one's own name, and disorientation as to time and place. Those levels of disability are greater than what the Veteran has shown throughout the appeal. For these reasons, the Board declines to remand this matter for referral for extraschedular consideration. ORDER Entitlement to an effective date prior to March 14, 2005, for the grant of service connection for an acquired psychiatric disorder, manifested by PTSD with MDD and anxiety, also associated with asbestosis, is denied. Entitlement to an initial disability rating in excess of 70 percent for PTSD is denied. ______________________________________________ Alexandra P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs