Citation Nr: 1339656 Decision Date: 12/03/13 Archive Date: 12/18/13 DOCKET NO. 10-40 278 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: John C. Blair, Attorney ATTORNEY FOR THE BOARD A. Lech, Associate Counsel INTRODUCTION The Veteran had active service from November 1969 to August 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The Board has reviewed the physical claims file and the Virtual VA electronic claims file. FINDINGS OF FACT 1. During the initial rating period prior to June 28, 2010, the date that the Veteran's statements regarding his worsening PTSD symptoms were received by the RO, the Veteran's PTSD was manifested by occupational and social impairment that most nearly approximated occasional decrease in work reliability. 2. As of June 28, 2010, the date that the Veteran's statements regarding his worsening PTSD symptoms were received by VA, the Veteran's PTSD has been manifested by occupational and social impairment that more nearly approximates reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for PTSD for the period prior to June 28, 2010, are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for a disability rating of 50 percent, but not higher, for PTSD as of June 28, 2010, are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA will assist a claimant in obtaining evidence necessary to substantiate a claim, but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. VA must notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary, that is necessary to substantiate the claim. As part of the notice, VA has to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), 38 C.F.R. § 3.159 (2013). The notice to a claimant should be provided at the time that, or immediately after, VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record shows that the Veteran was mailed a letter in June 2008 advising him of what the evidence must show and of the respective duties of VA and the claimant in obtaining evidence. The June 2008 letter also provided the Veteran with appropriate notice with respect to the disability-rating and effective-date elements of his claims. The Board also finds the Veteran has been afforded adequate assistance in response to his claim. The Veteran's service medical records are of record. Neither the Veteran nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claim. The Board is also unaware of any outstanding evidence. Neither the Veteran not the representative has claimed any error of notice. Therefore, the Board finds that the duties to assist and notify have been met. Legal Criteria The Veteran seeks an increased rating for service-connected PTSD. An October 2009 rating decision granted service connection for PTSD, and assigned a 30 percent rating, effective August 28, 2008, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. When an appellant seeks an increased rating, it will generally be presumed that the maximum benefit allowed by law and regulation is sought. A.B. v. Brown, 6 Vet. App. 35 (1993). As such, the Veteran's claim for an increased initial rating remains on appeal. Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. 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); 38 C.F.R. §§ 3.321(a), 4.1 (2013). If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.1 (2013). After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient. Above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2013). While the Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. 38 C.F.R. § 4.1 (2013); Francisco v. Brown, 7 Vet. App. 55 (1994). The Board will consider entitlement to staged ratings to compensate for any times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). PTSD is rated under Diagnostic Code 9411. That diagnostic code uses the General Rating Formula for Mental Disorders, which provides that a 30 percent rating is warranted for a mental disorder if it is productive of 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). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 50 percent rating is warranted for a mental disorder when there is 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 effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 70 percent rating is warranted for a mental disorder when 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; 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 inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but 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 (2002). In rating psychiatric disabilities, VA has adopted the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. of the, American Psychiatric Association (1994) (DSM-IV). That manual includes a Global Assessment of Functioning (GAF) scale which takes into consideration psychological, social and occupational functioning on a hypothetical continuum of mental illness. 38 C.F.R. § 4.125(a) (2013); Richard v. Brown, 9 Vet. App. 266 (1996). A score of 31 to 40 indicates 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; child frequently beats up younger children, is defiant at home, and is failing at school). A score of 41 to 50 indicates 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). A score of 51 to 60 indicates 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 peer or coworkers). American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (1994). The evidence for consideration in this case includes VA examination reports, private examination reports, and lay testimony and statements. The appeal stems from the initial grant of service connection. The Veteran has not challenged the August 28, 2008, effective date for the grant of service connection, and therefore, the relevant question in this matter is the state of his disability for the period beginning on August 28, 2008. 38 C.F.R. § 3.400 (2013). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim to disability or death benefits. 38 U.S.C. § 1154(a) (2013). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for VA benefits. VA shall consider all information and lay and medical evidence of record in a case before VA. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Analysis The Board has reviewed all evidence of record pertaining to the history of the service-connected disability. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2013); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). At a September 2009 VA examination, the examiner noted that the Veteran served as a Medical Corpsman in Vietnam from March 1971 to August 1971. The examiner noted that the Veteran indicated that he gambled and abused alcohol upon return from Vietnam, and that he worked many different jobs in coal mines over the years. The examiner stated that the Veteran had a history of becoming aggravated and quitting work, had difficulty concentrating and following instructions, and had a low frustration threshold, resulting in conflicts with co-workers. The examiner indicated that the Veteran was last employed in 2007, and that he stopped working due to a workplace injury. The examiner noted that the Veteran had been married since 1985, and that he loved and trusted his wife, but that they had many problems over the years. The examiner stated that the Veteran was an active member of his household, assisting his wife in decision-making and chores, and going out to shop for groceries. The examiner stated that the Veteran loved his children and grandchildren and felt close to them, and saw them almost daily, but the grandchildren sometimes overwhelmed him. The examiner stated that the Veteran reported being anxious and easily startled around his grandchildren. The Veteran reported going on family trips, but becoming anxious and wanting to leave after about two hours. The Veteran also reported being very close to his mother and siblings, whom he saw almost daily. The Veteran also stated that he had a close friend with whom he had contact every couple of days and that he attended church, but did not socialize much there. The Veteran reported enjoying attending sporting events, reading, and working around the house. The examiner noted that the Veteran went to the Vet Center for several psychiatric counseling visits, and that during a March 2000 appointment the Veteran was prescribed Celexa and Trazadone for symptoms consistent with PTSD, but that he never refilled the medications. The examiner noted that reports from the Veteran's primary care physician over the years consistently showed negative depression screens and positive PTSD screens. The examiner noted that the Veteran reported persistently elevated anxiety, arousal, and irritability. The examiner stated that the Veteran appeared dressed and groomed appropriately, was pleasant and cooperative, his speech was normal, he was well oriented, his reasoning was intact, he displayed average intelligence, and his attention and concentration were intact. The Veteran's immediate and recent recall were slightly impaired, his judgment and insight were fair, he displayed a full range of affect, and his thought process was goal-directed and well-organized. The Veteran denied suicidal or homicidal thoughts and delusional ideation, and stated that he had experienced intrusive trauma memories. The examiner noted that there were no perceptual oddities, and that the Veteran's contact with reality was intact. The examiner noted that the Veteran reported having trouble staying asleep, and waking up three-four times a night, often panicked and in a cold sweat. The Veteran reported having about five hours of sleep a night, and generally feeling well-rested. The Veteran also described symptoms consistent with an anxiety attacks, stating that they occurred occasionally. The examiner noted that the Veteran reported watching many people die in Vietnam, including seeing a baby being shot in the head and children burnt from napalm. The Veteran reported being told to take a young man's blood pressure as a joke, since the man's arms and legs had been blown off. The Veteran reported intense horror and helplessness during those situations. The examiner noted that the Veteran met the traumatic stressor criterion for PTSD. The examiner stated that the Veteran experienced intrusive trauma memories at least once a week, but that he was able to manage his distress well by going for a drive or engaging in activities. The Veteran experienced traumatic dreams once every couple of months, and psychological distress at exposure to internal or external clues, such as the sight of blood or television programs about war, that resembled or symbolized the traumatic event. That exposure occurred about once a month and resulted in very manageable distress. The Veteran reported an avoidance of activities, people, and places that triggered trauma memories, such as going to Veterans' parades or watching war movies, and reported that he engaged in distracting activities to avoid thoughts about Vietnam. The examiner stated that the Veteran felt detached from the people around him, and was less empathetic and sympathetic than he once was. The Veteran reported being irritated and raising his voice on a daily basis, experiencing mild difficulty maintaining sustained concentration, experiencing persistent hypervigilance, and needing to sit where he could see people coming and going. The examiner diagnosed the Veteran with PTSD, stating that he experienced mild to moderate symptoms of PTSD, resulting in generally mild functional impairment. The examiner assigned the Veteran a GAF score of 60, indicative of moderate symptoms or moderate difficulty in social or occupational functioning. The examiner opined that the Veteran was not totally occupationally impaired and was not unemployable. At a June 2010 VA examination, the Veteran told the examiner that he lived with his wife, and felt close to her, but liked to spend about five hours a day alone. The Veteran reported that he and his wife had recently adopted their four-year old granddaughter, with whom he enjoyed spending time and to whom he felt close, and that they were also taking care of a one-year old foster child. The Veteran reported seeing his children almost every day, and said that he felt close to his children. The Veteran reported seeing a close friend every three to four days, and talking to him daily. He engaged with friendly interactions with some of his neighbors and extended family. The Veteran stated that he helped around the house, did work outside and in the basement, and that he had not enjoyed fishing or hunting in about ten years because of los of interest. He also reported not attending baseball games as often as he used to. The examiner noted that the Veteran was clean, neatly groomed, and appropriately dressed. His psychomotor activity and speech were unremarkable. He was cooperative and friendly, displayed appropriate affect, and was anxious. The Veteran's attention was intact, he was oriented, and his thought process was unremarkable. He did not experience delusions, his judgment and insight were intact, and he did not report any hallucinations. The examiner stated that the Veteran experienced sleep impairment, being able to sleep four to five hours straight, with insomnia. The examiner noted that the Veteran exhibited inappropriate behavior by acting out verbally. The Veteran interpreted proverbs appropriately, did not exhibit any obsessive or ritualistic behavior, denied panic attacks, and denied suicidal or homicidal thoughts. The Veteran exhibited good impulse control, did not have any episodes of violence, and did not have any problems with activities of daily living. The examiner noted that the Veteran's remote memory was normal, his recent memory was mildly impaired (he had difficulty remembering birthdays and anniversaries), and his immediate memory was normal. The Veteran reported that he experienced intrusive, trauma-related thoughts about every two days, and that those thoughts made him isolate himself from others, but they did not result in him neglecting his responsibilities. The Veteran experienced two to three trauma-related nightmares a month, and psychological distress at exposure to cues such as blood or television programs about war, which occurred about once a month and was manageable. The Veteran reported avoiding most war movies and conversations about his experiences in service, especially with family and friends, with whom he could not talk in the same way as he could with his VA providers. The Veteran reported experiencing persistent, mild detachment from others, but reported having close relationships with family and one friend. The Veteran reported experiencing emotional restrictions and not grieving as intensely as be believed he should. The Veteran reported experiencing hypervigilance all the time, but said that it did not significantly disrupt his activities. He also reported having difficulty concentrating on activities and experiencing exaggerated startle response four to five times a week. The examiner evaluated two non-VA examinations presented by the Veteran. The first one was dated in December 2008 and January 2009. The VA examiner noted that that report did not address the frequency or intensity of the Veteran's symptoms and that it incorrectly described the Veteran's very vivid memories as "flashbacks," not addressing the actual definition of a flashback. The second external examination, dated in January 2010, described the Veteran as having "profound" PTSD, and the VA examiner noted that "profound" was not a diagnostic specifier applicable to PTSD. The VA examiner noted that the January 2010 examination assigned the Veteran a GAF score of 45, indicating severe symptoms, but did not address the frequency or severity of any symptoms mentioned in the report. The VA examiner stated that it was unclear how the January 2010 examiner diagnosed PTSD. The January 2010 examination also indicted that the Veteran was incapable of gainful employment, failing to take into account that he was gainfully employed until 2007 and stopped working due to physical injuries and medical issues. The VA examiner confirmed the diagnosis of PTSD stemming from combat stressors, and assigned the Veteran a GAF of 61. The examiner stated that the Veteran's symptoms were mild to moderate, with mild impairment of functioning. The examiner stated that the Veteran's symptoms had not been severe enough to require treatment, and that there was no evidence of total occupational impairment. The examiner opined that the Veteran was not unemployable due solely to the symptoms of PTSD. At a February 2011 VA examination, the examiner stated that the Veteran had experienced additional stressors since his last VA examination of being diagnosed with prostate cancer and having two sons with substance abuse problems, and that those issues exacerbated his PTSD symptoms. The examiner stated that the Veteran reported some symptoms of depression (dysphoric mood, despair, low energy and motivation), but those were partly due to the PTSD, and partly due to separate factors, and did not warrant a separate diagnosis. The Veteran reported to the examiner that he experienced some closeness to his wife, they ate meals together and spent some time together, but felt that she did not understand and irritated him. The Veteran stated that he withdrew to avoid conflict, which increased the conflict with his wife, as she wanted to do things together. The examiner stated that those issues, while present at the last VA examination, were somewhat worse at the present examination. The Veteran also reported that he was close to his children and grandchildren, but that he also withdrew from them. He saw a friend of his a few times a week, less frequently that he used to, and he did chores inside the house and outdoors. The examiner stated that, at the time of the last VA examination, the Veteran showed mild impairment in his functioning, and the impairment was increased and marked by intrusive thoughts, trauma nightmares, increased irritability, and increased avoidance and isolation. The examiner stated that the Veteran appeared unremarkable, with unremarkable psychomotor activity, his attitude was open and cooperative, his affect somewhat restricted, and mood varying from depressed to euthymic. The Veteran stated that he experienced problems with memory and attention. The examiner stated that the Veteran was oriented, and that his thought process varied from rational and relevant to overwhelmed, and obsessive to active attempts to avoid thinking. His thought content varied from focus on historical grief to current stress issues to future worries. The Veteran did not have delusions, exhibited sufficient intelligence, and his judgment and insight appeared intact. The Veteran reported four to five hours of sleep a night, with sleeplessness following nights when he experienced Vietnam-related nightmares, which occurred two to three times a week, up from two to three times a month reported at the last VA examination. The Veteran did not report any hallucinations; reported being "hateful," which led to marital conflict, isolation, and withdrawal; reported repeatedly checking doors and locks and sleeping with a loaded weapon in the closet; denied panic attacks; and denied suicidal or homicidal ideation, outside of the occasional despair regarding the point of life. The Veteran reported fair impulse control, but stated that he was often verbally inappropriate; denied episodes of violence; stated that he was able to maintain personal hygiene and grooming, but sometimes failed to due to low motivation, his hygiene and grooming were appropriate for the examination; reported that he did some household and outdoor chores, including shopping in the off-hours when there were fewer people around; stated that he exercised a little, but was physically limited; and reported that he drove, but was distracted and got lost easily. The examiner stated that the Veteran's short term memory varied from intact to impaired and long term memory was intact. The examiner stated that the Veteran reported experiencing trauma-related recurrent and intrusive memories of moderate to severe intensity on most days, an increase from last examination, when he reported those occurring a few times a week; trauma dreams of moderate to severe intensity two-three times a week, an increase from two to three times a month; intense distress and physiological reactivity when exposed to symbolic cues of moderate intensity several times a week, an increase from the last examination; persistent efforts to avoid thinking about or discussing the trauma experience; persistent diminished interest or participation in activities with moderate to severe intensity, an increase since the last examination, but only part of it due to PTSD and part to separate factors; occasional restricted range of emotional effect of moderate intensity; occasional detachment of moderate intensity; sleep disturbance on most nights, of moderate to severe intensity; irritability on most days, of moderate to severe intensity; problems concentrating at times, of moderate to severe intensity; persistent hypervigilance, of moderate to severe intensity; and frequent startle response, of moderate intensity. The examiner noted that the Veteran stated that his symptoms appeared upon returning from active service, and that he had not experienced any remission from his symptoms. The examiner noted that the Veteran had worked in the coal mines for 25 years until 2007 when a work injury forced him to retire. The Veteran stated that he was a good worker and functioned well at work, particularly when busy, and that some PTSD symptoms surfaced when he was less busy. The Veteran stated that while his irritability caused him some conflict at work, his symptoms did not prevent him from working and he was always able to find and maintain work. The examiner confirmed the diagnosis of PTSD and assigned the Veteran a GAF score of 50. The examiner stated that the Veteran showed some worsening of PTSD symptoms, some of which were related to PTSD, and some to separate stressors which exacerbated the PTSD symptoms. The examiner stated that the severity of the Veteran's PTSD symptoms was moderate to severe, with distress at times severe, and impairment due to PTSD symptoms overall was moderate. The examiner stated that the Veteran had not sought treatment for his PTSD, although he did state that he was thinking about it. The examiner stated that if he were physically able to, with some interference from his PTSD symptoms, the Veteran would be able to be gainfully employed, and that the Veteran was not deemed totally occupationally impaired due to the PTSD. At a private examination in December 2008 and January 2009, the Veteran reported to the examiner that he liked to be by himself a lot, that he no longer hunted or fished, which he used to enjoy, and that he no longer had the energy he used to have. The Veteran told the examiner that he used to attend individual therapy at VA, but that the therapist told him that he was crazy when the Veteran reported to the therapist that he heard things that other people did not hear. The Veteran told the therapist about his service in Vietnam, and about the many people he saw die when he was a medic trying to administer aid to the people who returned from combat. The Veteran reported to the examiner that he experienced hallucinations, 90 percent of which were war-related. The examiner noted that the Veteran reported hearing traffic during the examination, when there was no traffic according to the examiner, and that he could hear squirrels climbing up trees and birds up in the trees apparently ever since childhood. The Veteran reported that his wife slept in a different room because the Veteran acted out violently in his sleep. The Veteran also reported that he did not tell people things, especially over mobile phones, due to uncertainty as to who was listening in. The Veteran told the examiner that he liked to be by himself a lot, and that he consistently saw shadows outside of his home. The Veteran reported disliking being in a crowd and loud noises. The examiner noted that the Veteran avoided any reminders of war, such as movies and newspapers, and that certain smells, such as something burning, triggered his memories of Vietnam. The Veteran reported that he saw many babies die in the hospital in Vietnam and many kids burnt with napalm, and that he loved children now because he saw so many of them hurt then. The Veteran reported that his job while in active duty forced him to be callous. The examiner also noted that the Veteran used to drink heavily and that he worked in the coal mines for 25 years, retiring in April 2008 due to a number of injuries. The Veteran reported that he watched TV at home, had gained weight, and had an increased appetite. He was able to complete some daily responsibilities, and had less interest in activities and less energy, and decreased contact with family members and friends. The examiner noted that the Veteran was appropriately dressed and groomed, was friendly and cooperative, had good eye contact, elaborated appropriately on questions asked, and did not have a sense of humor. The Veteran's speech was normal, he was oriented, his mood was depressed, and his affect blunted. The Veteran's thoughts were logical, emotional reactions relevant to thought content, and active psychotic thought patterns were not evident. The Veteran did not admit to any obsessive-compulsive thoughts, denied phobias, and denied active homicidal or suicidal ideation, but admitted to having those in the past. The examiner stated that the Veteran had some insight into his problems, exhibited average judgment, and his immediate memory was normal. The Veteran's recent memory was moderately deficient, and remote memory was mildly impaired. His concentration was moderately deficient. The examiner diagnosed PTSD and severe major depressive disorder, with psychotic features. The examiner noted that the Veteran's PTSD was caused by service, and that the PTSD caused the Veteran to be impaired or disabled. The examiner noted that the Veteran was markedly limited in his functioning, and that he was disabled from the PTSD so as to prevent him from gainful employment. The examiner noted the Veteran had recurrent and distressing recollections of the event, recurrent and distressing dreams, flashbacks, and intense psychological distress. The examiner noted that the Veteran persistently avoided stimuli, thoughts, feelings, and situations associated with the trauma; that he was unable to recall an important aspect of the trauma; that he had marked diminished interest in significant activities; that he felt detached and estranged from others; and that he had a restricted range of affect. The examiner also noted that the Veteran had difficulty sleeping; experienced irritability or outbursts of anger; had difficulty concentrating; experienced hypervigilance and exaggerated startle response; and physical reactivity upon exposure to events that symbolized or resembled the traumatic event. The examiner described the Veteran as 85 percent disabled and assigned him a GAF score of 41 to 50. At a January 2010 private psychiatric evaluation with Dr. N.D., the doctor noted that the Veteran witnessed many injuries during his active service, including fatally wounded children. The examiner stated that the Veteran continued experiencing flashbacks and nightmares, felt irritable, tired, and lost his temper easily. The examiner stated that the Veteran preferred to be alone, cried easily, did not sleep well, and was restless at night due to nightmares. The Veteran denied any suicidal or homicidal ideation. His appetite was fair, he did not report any weight loss or gain, but did report difficulty concentrating, remembering, and dealing with stress. The Veteran reported developing headaches and having chest and stomach pains when he got nervous or upset. Dr. N.D. noted that the Veteran helped with household chores, did not go out to visit, and went out to shop only for necessities. The Veteran reported to the doctor that he watched TV and attended church services, but no longer enjoyed hunting or fishing. Dr. N.D. noted that the Veteran was prompt for his appointment, was withdrawn, and neatly and casually dressed. His affect was anxious, and his mood depressed and agitated. He was oriented, but had a difficult time expressing his thoughts and relating to the examiner. The doctor noted that the Veteran's speech revealed frustration and his eye contact was limited. The Veteran's recent and remote memory were intact, and he had no difficulties with recall. His impersonal judgment was intact; he interpreted proverbs correctly; his abstract thinking was intact; and he appeared to have a fair amount of insight into his difficulties, but low self-esteem. The Veteran did not appear to have hallucinations or delusions during the interview. Dr. N.D. diagnosed the Veteran with PTSD-Profound and Neurotic Depression-Severe, assigning him a GAF of 45. Dr. N.D stated that the PTSD affected the Veteran's daily life significantly, that he did not appear to tolerate much stress or any gainful employment, and that he was not a good candidate for vocational rehabilitation. The Veteran has submitted several statements in support of his claim. In a September 2008 statement, the Veteran reported that he watched many men, women, and children die when he was stationed in Vietnam. He stated that, for several years after returning to the United States, he had trouble adjusting to life and worked on and off starting in 1974. The Veteran stated that he liked being mostly by himself, and that he used to have a severe drug and alcohol problem. He stated that he was no longer able to work due to the injuries he had experienced in his work at the coal mines. In June 2010, the Veteran submitted another statement to update VA on his condition. He stated that he was progressively worse and that his wife had to quit her job to take care of him, as he was increasingly forgetful and a bit disoriented at times. The Veteran stated that it bothered him that his wife had to take care of him, but that he had to accept that he no longer could do it himself. The Veteran stated that he liked being alone and liked to go out alone. The Veteran stated that he was intimidated and found it difficult to talk at the evaluation performed by Dr. N.D., and did not tell her many of his problems. The Veteran stated that he heard noises and saw things, such as shadows, when others could not. He stated that he told a VA psychologist about it, but that the psychologist said that he was crazy, which bothered him and made it difficult for him to talk to people about his experiences in Vietnam. The Veteran stated that he did not have any of those problems before going to Vietnam. The Veteran stated that he had problems relating to people, got irritable, was a little paranoid, and easily angered. He said that he had nightmares and flashbacks. He said that he was depressed and anxious, and it was difficult for him to even shower on a regular basis. The Veteran stated that he had thought about suicide in the past. He said that he could no longer work due to the PTSD and age-related physical disabilities, that he experienced memory loss, lack of concentration, and found it difficult to get along with co-workers. He stated that he did not wish to seek treatment for PTSD, as that would only bring up everything and make his nightmares worse. The Veteran also stated that he "zoned out," and that his problems were exacerbated by lack of sleep. He said that he was restless, hyper, nervous, irritable, angry, and easily startled. The Veteran also stated that he no longer enjoyed the things he used to when he was younger, that he did not like to leave the house, that he forgot his children's birthdays and his wedding anniversary, and that he depended on his wife for everything from grocery shopping to remembering his doctor's appointments and doing all the housework. The Veteran stated that he saw many people die in Vietnam, including children, and that it was bad enough to see soldiers wounded and killed, but that nothing could prepare one for the sight of such things happening to children. The Veteran stated that those memories never left him, and that he and his fellow soldiers learned to numb themselves to the war by drinking. The Veteran stated that he avoided watching war shows, or anything that reminded him of Vietnam, and that he was unsure that he would ever get better, as he only seemed to get worse with age. The Veteran's wife, H.M., submitted a statement on his behalf that she believed that her husband's condition was worsening. She stated that the Veteran was up at all hours of the night, and was more easily angered and more irritable than ever before. She said that he would disappear, sometimes taking off in his vehicle, not telling her where he was going or when he would return. H.M. stated that the Veteran would snap at her and the children over small things. She used to work part-time, but had to quit her job because she worried about him forgetting things like leaving the stove on. H.M. stated that the Veteran had days when he just wanted to be left alone, avoiding responsibility such as taking care of the children when H.M. was at work. Three of the Veteran's siblings submitted statements on his behalf in June 2010. A.W. stated that the Veteran was an outgoing, funny person growing up, but that his personality had changed when he returned home from Vietnam, and that he seemed upset a lot. P.L. stated that the Veteran had changed a lot since he returned from Vietnam, and seemed to have gotten worse as the years passed. P.L. stated that the Veteran was moody, standoffish, wanted to be left alone, had a bad temper and a short fuse, and was hateful and angry. She stated that the Veteran said hurtful things to others, lost control of his temper, screamed at people, and threw objects. P.L. stated that sometimes the Veteran appeared not to care what he looked like in public. C.M. stated that the Veteran's personality had changed since he returned home from Vietnam, and that he was agitated, anxious, and easily startled. She stated that the Veteran seemed more anxious at family gatherings, when there were many people around, and seemed less anxious around fewer people. C.M. stated that the Veteran had flashbacks and was unable to sleep well, and that those problems persisted. She also stated that the Veteran had a monotone voice at times, which she ascribed to depression. The Board finds that the Veteran is not entitled to a disability rating in excess of 30 percent for the period prior to June 28, 2010, for PTSD. Prior to June 28, 2010, the Veteran's PTSD was productive of 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, sleep impairment, mild memory loss, such as forgetting names, directions, or recent events. While the Veteran reported anxiety, irritability, and hypervigilance to his examiners, he was able to maintain a job at the coal mines for 25 years and, while he sometimes experienced conflicts with co-workers, he was able to find and maintain work, and retired only after a work-related physical injury. While the Veteran experienced some conflicts with his wife, and some detachment and the need to be alone, he was close to her, their children, and grandchildren, whom he saw daily. The Veteran also had a friend, whom he saw almost daily, he went grocery shopping, went on family trips, attended church, enjoyed attending sporting events, and worked around the house. While the Veteran's memory was slightly impaired, his judgment and thought processes were intact, and he displayed a full range of affect. While the Veteran acted out verbally, he exhibited impulse control and did not act out physically. The Veteran denied suicidal or homicidal ideation and had full contact with reality. While the Veteran reported having nightmares about Vietnam and intrusive thoughts about it, the traumatic dreams occurred one to three times a month, and the thoughts every few days. While the Veteran experienced hypervigilance and exaggerated startle response, he was also able to maintain personal hygiene and had no problems with everyday activities. The Veteran was able to manage his distress by going for a drive or engaging in other activities. The two private examinations provide a picture of the Veteran's symptoms that was consistent with the one that emerged from the VA examinations. At the December 2008 and January 2009 private examination, the Veteran reported having hallucinations and paranoia, but all the other reported symptoms were very similar to, or the same as, those reported at the VA examinations. The examiner did not note the frequency or severity of the Veteran's symptoms. While the examiner diagnosed the Veteran with PTSD and major depressive disorder with psychotic features and declared the Veteran incapable of maintaining gainful employment, that conclusion was inconsistent with the rest of the symptomatology described by the examiner, which more closely approximated mild to moderate impairment. The conclusion was also inconsistent with the fact that the Veteran had a career in the coal mines spanning 25 years, and that the Veteran only stopped working when a work accident made it physically impossible for him to work. At the January 2010 examination, the examiner described symptoms which, again, were very similar to, or the same as, those reported at the VA examinations. The examiner diagnosed the Veteran with "profound" PTSD, a diagnostic criteria that is not used to diagnose PTSD according to the DSM-IV, as noted by a VA examiner. The examiner did not explain what criteria were used to diagnose the Veteran. Again, the examiner did not note the frequency or severity of the Veteran's symptoms. Again, while the examiner diagnosed the Veteran with PTSD-Profound and Neurotic Depression-Severe, assigning him a GAF score of 45, and declared the Veteran incapable of maintaining gainful employment, that conclusion was inconsistent with the rest of the symptomatology described by the examiner, which more closely approximated mild to moderate impairment. The conclusion was also inconsistent with the fact that the Veteran had a career in the coal mines spanning 25 years, and that the Veteran only stopped working when a work accident made it physically impossible for him to work. The September 2009 examiner ascribed the Veteran a GAF score of 60, the January 2010 examiner a GAF score of 45, and the June 2010 examiner a GAF score of 61. The GAF score is one of the indicia that can be used to assess the Veteran's overall disability picture. In this case, the January 2010 GAF score differs sharply from the other two scores. The other two scores are more consistent with the overall picture provided by the Veteran's symptomatology before June 28, 2010, when his symptoms were consistently judged by mental health professionals to be mild to moderate. The 45 GAF score is also inconsistent with the findings in the report from which it stemmed, where the Veteran's enumerated symptoms showed mild to moderate impairment. Viewed as a whole, and because the GAF score is only one of the factors which are considered, the Board finds that the symptoms exhibited by the Veteran more nearly approximate those contemplated by the 30 percent disability rating before June 28, 2010. Therefore, a rating greater than 30 percent is not warranted prior to June 28, 2010, because the evidence did not show occupational and social impairment with reduced reliability and productivity due to the psychiatric symptoms. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). The Board finds that the Veteran is entitled to a disability rating of 50 percent, but not higher, as of June 28, 2010, for PTSD. As of June 28, 2010, the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial; impairment of short-term; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. The Veteran submitted a statement in June 2010 in which he reported that his symptoms had become progressively worse. The statements from the Veteran's wife and siblings corroborated the Veteran's worsening condition. The February 2011 VA examination showed that the Veteran had experienced additional stressors since his June 2010 examination (a diagnosis of prostate cancer and the substance addiction of his two sons), and that those stressors exacerbated the PTSD symptoms. The Veteran exhibited increased intrusive thoughts and trauma nightmares; increased irritability; increased isolation from his family and friends; a restricted affect; a depressed mood; a thought process that varied from rational and relevant to overwhelmed and obsessive; attempts to avoid thinking about stressors; stressor-filled thought content; being verbally inappropriate with his family; and being paranoid. The Veteran did not exhibit or report any hallucinations; panic attacks; suicidal or homicidal ideation; or episodes of violence. While the Veteran's short term memory was impaired, his judgment and impulse control were intact. While the Veteran experienced low motivation, he regularly performed household and outdoor chores, maintained personal grooming and hygiene, and drove his car. Furthermore, he maintained relationships. While the Veteran was not working at the time of the examination, he was noted to had been a good employee, with some interpersonal conflicts at work, who worked in the coal mines for 25 years and retired due to physical injuries experienced on the job. The examiner assigned the Veteran a GAF score of 50. That score indicated that the Veteran experienced moderate to severe impairment. Specifically, the Board notes that the examiner stated that the Veteran's distress was severe at times, and impairment due to PTSD symptoms was moderate overall. That score is consistent with the increased intensity and severity of symptoms the Veteran had reported, as documented by both the VA examination and the statements of the Veteran, his wife, and his siblings. Viewed as a whole, and because the GAF score is only one of the factors which are considered, the Board finds that the symptoms exhibited by the Veteran more nearly approximate those contemplated by the 50 percent disability rating. Therefore, a 50 percent rating, but not higher, shall be assigned to the Veteran for the period beginning June 28, 2010. The Board finds that a higher rating is not warranted because the evidence does not show occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to psychiatric symptoms as of June 28, 2010. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). The Board acknowledges that the results of the VA examinations and the symptoms described in the VA examination reports, private examination reports, and lay statements do not indicate that the Veteran experiences all of the symptoms associated with a 50 percent disability rating for a psychiatric disability. However, the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather should serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, a finding that there is occupational and social impairment resulting in reduced reliability and productivity is sufficient to warrant a 50 percent disability rating, even though all the specific symptoms listed for a 50 percent rating are not manifested. Consideration has been given to assigning a higher rating as of June 28, 2010. However, there is no indication from the evidence of record that the Veteran has experienced occupational and social impairment with deficiencies in most areas during as of June 28, 2010. The Veteran did not show such symptoms as 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. At all the examinations, the Veteran's speech was generally unremarkable; he was well-oriented, well-groomed, and neatly dressed; his behavior was appropriate; and he was able to function well independently both socially and in previous jobs. He described having a good relationship with his wife and children, denied panic attacks, and stated that he had coping strategies, such as going for a drive, for managing his symptoms. While he stated that he sometimes had difficulty with others on the job, the Veteran has been able to maintain a job for 25 years prior to retiring due to physical problems. While the Veteran reported occasional hallucinations, he reported hearing and seeing things to only two examiners, and specifically denied hallucinations to all the other examiners. While the lay statements show some problem with independent functioning, the evidence does not show that was sufficient to support deficiencies in most areas to warrant a higher rating. Therefore, a higher rating is not warranted as of June 28, 2010. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1) (2013). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for the disability are inadequate. Therefore, 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 that 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. Thun v. Peake, 22 Vet. App. 111 (2008). The record shows that the manifestations of the Veteran's disability are contemplated by the schedular criteria. There is also no indication from the evidence of record that the Veteran has had frequent hospitalizations or even received frequent emergency treatment for PTSD. Additionally, the Veteran had been able to work steadily for 25 years and his current symptoms of PTSD have not rendered him unemployable. While the private examiners suggested that the Veteran was unemployable, that finding was rebutted by the VA examiners. The Board finds that VA examination reports more persuasive because they recite substantially similar symptomatology to the private reports and explain that the Veteran would not be precluded employment by his symptoms. It is not merely being unable to do the previous job, but being unable to perform work suitable with training. In sum, there is no indication that the average industrial impairment from the disability would be to such a degree as to warrant the assignment of a higher disability rating than those assigned. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not warranted. ORDER Entitlement to an increased rating for PTSD, greater than 30 percent, prior to June 28, 2010, is denied. Entitlement to an increased rating of 50 percent, but not greater, for PTSD, as of June 28, 2010, but not earlier, is granted. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs