Citation Nr: 1341328 Decision Date: 12/16/13 Archive Date: 12/31/13 DOCKET NO. 10-22 612A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUE Entitlement to an initial disability rating in excess of 70 percent for service-connected posttraumatic stress disorder (PTSD) prior to April 10, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. Dodd, Associate Counsel INTRODUCTION The Veteran had active service from September 1970 to June 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision issued by the Department of Veterans Affairs (VA), Regional Office (RO), in Albuquerque, New Mexico, in which the Veteran was granted service connection for PTSD and an initial 50 percent disability rating was assigned, effective as of October 23, 2001. The Veteran expressed disagreement with the assigned initial disability rating and perfected a substantive appeal. In a December 2011 rating decision, the initial disability rating for the service-connected PTSD was increased by the RO from 50 percent to 70 percent, effective as of October 23, 2001. Thereafter, in November 2012, the RO determined that the PTSD warranted a 100 percent disability rating, effective April 10, 2012. As the 100 percent disability rating is the maximum rating available for PTSD from April 10, 2012, the appeal is considered satisfied with regard to that time period, and the scope of the current appeal now only includes the period prior to that date. As such, the caption page has been amended to reflect the revised scope. With regard to the issue of a disability rating in excess of 70 percent prior to April 10, 2012, applicable law provides that absent a waiver, a claimant seeking a disability rating greater than assigned will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and that a claim remains in controversy where less than the maximum available benefits are awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran has not withdrawn the appeal as to the issue of the disability rating greater than assigned, therefore, the issue remains in appellate status. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that an Appellant's Brief has been submitted on behalf of the Veteran by his representative. The Virtual VA paperless claims file also contains copies of the Veteran's VA outpatient treatment records dated April 2012 to May 2012. These records have all been considered by the Board in adjudicating this matter. The remaining documents in the Virtual VA paperless claims file are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a total disability rating based on individual unemployability (TDIU) claim is part of an increased rating claim when such claim is raised by the record. As of this writing, this issue has not been raised by the record, as the evidence shows that, prior to the receipt of a 100 percent disability rating for PTSD effective April 10, 2012, the Veteran had been employed full time continuously during all periods pertinent to the present appeal. In this regard, on VA examination in April 2011, it is noted that the Veteran had been working full time as a construction project manager for the preceding five to 10 years. As such, no further discussion of this issue shall ensue. FINDINGS OF FACT 1. Prior to April 27, 2011, the Veteran's service-connected PTSD was manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: difficulty in adapting to stressful circumstances (including work or a work like setting), disturbances in mood, near-continuous depression and anxiety, irritability, suicidal ideation, homicidal ideation, near-continuous panic attacks, compulsive rituals, sleep impairment, nightmares, and memory loss. 2. Resolving all reasonable doubt in the Veteran's favor, from April 27, 2011, the service-connected PTSD was manifested by total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disturbances in mood, near-continuous depression and anxiety, irritability, suicidal ideation, homicidal ideation, near-continuous panic attacks, compulsive rituals, sleep impairment, nightmares, and memory loss. CONCLUSION OF LAW 1. Prior to April 27, 2011, the criteria for an initial disability rating in excess of 70 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code 9411 (2013). 2. From April 27, 2011, the criteria for a 100 percent disability rating for service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The Veteran's claim arises from his disagreement with the initial disability rating following the grant of service connection. Courts have held that, once service connection is granted, the claim is substantiated and additional notice is not required. Thus, any defect in the notice provided to the Veteran is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Nevertheless, in correspondence provided by the RO, the Veteran was notified of the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Next, the VCAA requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran's relevant service, VA, and private medical treatment records have been obtained. There is no indication of any additional, relevant records that the RO failed to obtain. The Veteran was medically evaluated in March 2006, June 2008, April 2011, and April 2012. In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. Increased disability ratings Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, 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. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Veteran is appealing the initial assignment of a disability rating, as such, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2013). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14 (2013) (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). The Veteran's service-connected PTSD is rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). PTSD is rated under the General Rating Formula for Mental Disorders, which provides that: A 100 percent disability rating is warranted if there is 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. A 70 percent disability rating is warranted 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 worklike setting); inability to establish and maintain effective relationships. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased disability rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994); 38 C.F.R. § 4.125 (2013). A GAF of 31 to 40 is defined as exhibiting some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or any 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 GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). The Veteran contends that his PTSD is worse than reflected by the 70 percent disability rating during the time period prior to April 10, 2012. In a December 2002 notice of disagreement, he indicated that he experienced symptoms of depression, sleep impairment, feelings of worthlessness, and anxiety since leaving service. In September 2013, the Veteran testified at a Board hearing as part of his prior claim of service-connection for PTSD. During that hearing, he testified that he had experienced symptoms of depression every day since leaving service. Further, he indicated that he was taking medication to treat his condition. He endorsed feelings of irritability, anger, and rage as well as suicidal and homicidal ideation. He added that he had trouble keeping jobs after service. In a September 2003 lay statement from a fellow service member, it was indicated that the Veteran displayed symptoms of depression, isolation, nightmares, suicidal ideation, and marriage problems. VA outpatient treatment records dated from September 2003 to October 2004, the Veteran was noted as having symptoms of interpersonal problems at work, moderate risk suicidal ideation, chronic sleep impairment, irritability, depression, anxiety, nightmares, rage, intrusive thoughts, and social isolation. He was diagnosed with severe chronic PTSD. GAF scores ranged from 45 to 47. He was said to be taking medication, which he reported had lessened his depression. In a November 2004 statement, the Veteran indicated that he still had recurring nightmares about Vietnam; that he had to get up during the night to check doors and windows; that he had an inability to trust people; that he would tend to isolate from friends and family; and that he was hypervigilant. In a February 2005 VA outpatient treatment note, the Veteran was seen regarding his concern about possibly being fired from his job due to his PTSD. He was noted to be working full time. A GAF score of 49 was assigned. A VA examination report dated in March 2006 shows that the VA examiner noted that the Veteran had reported symptoms of PTSD since leaving service, and that he was currently taking medication. It was indicated that he had a fair marital and family relationship. He was considered a loner, with the exception of his Veteran friends, and had no social life. A history of assaultiveness and substance abuse was noted. He was said to exhibit depression, anxiety, anger, social isolation, and sleep problems. Affect was normal, and mood was anxious and depressed. Judgment and insight were fair to poor. His sleep impairment and occasional panic attacks were found to be severe. He was also noted to have occasional homicidal and suicidal thoughts. Memory was fair to poor. The diagnosis was chronic PTSD and a GAF score of 50 was assigned. It was noted that the Veteran's PTSD had caused changes in his employment performance, family role functioning, social and interpersonal relationships, and recreation and leisure pursuits. To this effect, it was noted that he had been threatened with termination at work. The prognosis was that his condition would improve with treatment. In an August 2006 statement, the Veteran indicated that, after he left the service, he did not want to think about Vietnam anymore so he began drinking whenever he was not working. He added that, as a result, his wife and family suffered. A VA examination report dated in June 2008 shows that the Veteran reported continued complaints of PTSD symptoms since leaving the service. It was noted that he was taking medication. He reported continual difficulty with employment since leaving service, and that he had been missing work lately due to his wife leaving him. However, it was indicated that he was full-time employed and married for 36 years, although currently separated. He described being physically and verbally violent with his wife, and that his relationship with his children was "rocky." He mentioned two close Veteran friends and a brother, with whom he socialized to get through tough times. Social functioning impairment was said to be moderate to severe. He was said to exhibit chronic symptoms of hopelessness, suicidality, anger, and poor sleep. He added that since his separation from his wife, he would have decreased pleasure in doing things, poor appetite, and low energy. A history of alcohol abuse was noted. His mood was said to be depressed. The diagnosis was chronic, moderate PTSD. A GAF score of 48 was assigned. His depressive symptoms, however, were noted as not being related to the PTSD. In a June 2008 VA outpatient treatment record shows that the Veteran reported symptoms of depression, anxiety, panic, anger, rage, paranoia, nightmares, sleep impairments, and mood swings, which were said to have worsened. He was also noted to have suicidal ideation that was of a low risk. In a June 2009 statement, the Veteran indicated that he could no longer sleep or rest without having to engage in checking activities. He stated that he was always on edge and did not trust anyone. In his August 2009 notice of disagreement, he indicated that he had a history of suicidal ideations and attempts that were not included in his VA examinations. He also indicated that he was depressed because his wife had left him due to his irritability, mood swings, binge drinking, depressive feelings, nightmares, and suicidal thoughts. In an August 2009 lay statement from a fellow Veteran, it was indicated that the Veteran displayed symptoms of depression, being withdrawn, easy to startle, inability to be in large crowds or loud noises, and suicidal ideation. In an April 2010 treatment record from the Vet Center, it was indicated that the Veteran reported symptoms of anger, rage, shame, grief, depression, guilt, intrusive memories, paranoia, distrust, hypervigilance, withdrawal, and pronounced issues with authority. He was assessed with a high degree of social and occupational impairment, however, it was not noted that such was total. In a May 2010 VA outpatient treatment record, the Veteran reported worsening of PTSD symptoms, that included social avoidance, anxiety, irritability, anger, hopelessness, depressed mood, and lack of interest and pleasure. The diagnosis was PTSD with depression. It was noted that he was independent with all activities of daily living, not at risk for suicide, and had good support from friends and family. In his June 2010 Appeal To Board Of Veterans' Appeals (VA Form 9), the Veteran indicated that his wife would leave him periodically due to his symptoms for periods of up to a month at a time. He also continued to endorse symptoms of hypervigilance, chronic sleep impairment, and rechecking compulsions. In a March 2011 lay statement from one of the Veteran's coworkers, it was indicated that he was having trouble with memory and calculation tasks at work. It was also noted that he tended to isolate from other employees at work. A VA examination report dated in April 2011 shows that it was noted that, despite aggressive and continuous treatment, the Veteran's condition had worsened. His symptoms included rage attacks, depressed mood, and suicidality. In this regard, his rage at work and suicidal impulses were said to be of significant concern. His relationship with his wife was described as "stormy," with his wife leaving for certain periods of time. He had few social relationships with some of his fellow Veterans. It was noted that he would frequently think of committing suicide while driving, has stalked his boss, and frequently scared people at work. His mood was noted as hopeless, happy, expansive, depressed, and fearful. Thought content revealed suicidal ideation, homicidal ideation, ruminations, and paranoid ideation. Chronic sleep impairment, nightmares, inappropriate behavior, compulsive checking, daily panic attacks, poor impulse control, and a history of violence were all identified. Recent and immediate memory was mildly impaired. Effects on activities of daily living included severe effects in engaging in sports/exercise, driving, and other recreational activities; moderate effects in household chores, grooming, toileting, and bathing; no effects on dressing, and preventing shopping. The diagnosis was PTSD. A GAF score of 40 was assigned. The examiner noted that he was currently working, but should not because of suicidality and rage. It was also noted that his wife would frequently leave him because of his rage. In a May 2011 VA outpatient treatment note, it was noted that the Veteran was forgetful and less motivated at working. His isolation was increasing. He continued to exhibit chronic sleep impairment, irritability, and suicidal ideation. In a June 2011 VA outpatient treatment note, it was noted that the Veteran had two friends he would call when stressed. He reported symptoms of sleep impairment, nightmares, decreased motivation and energy at work, and difficulty concentrating at work. The diagnosis was chronic PTSD and depression. In an additional June 2011 note, the Veteran was noted as sleeping better with medication. However, he was still experiencing depression and suicidal ideation. In a January 2012 statement, the Veteran indicated that his symptoms currently included an inability to stay on task or focused, reduced productivity and efficiency, reduced communication, anger and rage outbursts, persistent delusions, confusion with job tasks, paranoid delusions, including thoughts of harming co-workers, thoughts of hurting self and others, impaired abstract thinking, loss of motivation and interest, persistent thoughts of retaliation and destruction, disorientation to time, place, and situation, memory loss, inability to function independently, authority issues, disassociation, negativity, pessimism, grossly inappropriate behaviors, increasing difficulties with activities of daily living, flattened affect, difficulty establishing and maintaining relationships, difficulty in adapting to new work issues and reestablishing old work task, and suicidal ideation. PTSD Prior to April 27, 2011 Having carefully considered the evidence of record, the Board finds that the Veteran is not entitled to an initial disability rating in excess of 70 percent prior to April 27, 2011. Initially, the Board finds that the Veteran's GAF scores prior to April 27, 2011, were predominantly in the range of 45 to 50, with the scores trending closer to 50 towards the latter half of this time period. As noted above, a GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social or occupational functioning. Thus, the Veteran's GAF scores alone reflect PTSD that he was of an overall serious nature, but not quite to the level of a major impairment that would cause him to be totally occupationally and socially impaired. These scores, therefore, do not merit the assignment of a 100 percent disability rating for the PTSD, as a 100 percent disability rating requires a more severe impairment manifested by 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 an inability to work). Id. The Veteran's GAF scores alone cannot serve as the sole basis for evaluating his claim for a higher initial disability rating. All pertinent evidence of record must be considered and the Board's decision must be based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. In this regard, the Veteran's statements regarding his symptoms continuing throughout his life since he left service, include difficulties with maintaining his occupation and isolation from family and friends. The Veteran is competent to testify as to the severity of the symptomatology associated with his service-connected PTSD during the time period in question. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). His statements are presumed credible because his reported symptoms have been consistent in both his lay testimony and in what he reported to his treating providers in the medical evidence of record. His statements provide competent and credible evidence of disturbances in mood, near-continuous depression and anxiety, rage, irritability, difficulty sleeping, nightmares, social isolation, panic attacks, compulsive rituals, and memory loss. Further, the lay statements submitted by the Veteran's friends and co-worker, corroborate that he had been experiencing increased difficulties at home, with family, and work over the preceding couple of years due to the progression of the PTSD symptoms. The Veteran's overall serious symptoms were present throughout the period prior to April 27, 2011. All of this evidence persuasively suggests that, during the time period prior to April 27, 2011, the Veteran's service-connected PTSD was manifested by just occupational and social impairment with deficiencies in most areas because his PTSD symptoms were serious and affected his occupation, family life, and social life. However, he was still able to maintain full-time employment, albeit with decreasing reliability and productivity for the duration of the time period in question, as well as minimal socialization with family and friends. For instance, it was noted that a few of his fellow Veteran friends were a source of support for him in times of stress. Further, he was continually married during the time period in question with children and grandchildren. His medical records from the time period in question contained consistent reports of symptoms of difficulty in adapting to stressful circumstances (including work or a work like setting), disturbances in mood, near-continuous depression and anxiety, irritability, suicidal ideation, homicidal ideation, near-continuous panic attacks, compulsive rituals, sleep impairment, nightmares, and memory loss. All of these symptoms are either included in the list suggested by the Rating Schedule in assigning a 70 percent disability rating for PTSD or similar to symptoms reflective of that degree of impairment. Accordingly, the Board finds that the overall disability picture over the period on appeal prior to April 27, 2011, most closely approximates the criteria for a 70 percent disability rating. Consideration has been given to additional staged ratings since the date of the Veteran's claim (i.e., different percentage ratings for different periods of time). See Fenderson, 12 Vet. App. at 119. However, there appears to be no identifiable period of time since the date of claim during which the PTSD warranted a disability rating higher than 70 percent. PTSD from April 27, 2011 The Board finds that the evidence of record supports the criteria for the assignment of a 100 percent disability rating from April 27, 2011, for the Veteran's service-connected PTSD. In this regard, the VA examination report dated in April 2007 shows that the Veteran's GAF score was 40 which is indicative of some impairment in reality testing or communication or major impairment in several areas, such as work, family relations, judgment, thinking, or mood. Thus, the Veteran's GAF score alone reflects PTSD that was productive of major impairment that led to total occupational and social impairment. Although these scores alone do not merit the assignment of a 100 percent disability rating for the Veteran's service-connected PTSD, they do give an indication that the Veteran's condition had substantially worsened as of April 27, 2011, and, when coupled with the types of symptoms that the Veteran had begun to experience, show a greater overall disability picture reflective of total occupational and social impairment. The Board also finds that the Veteran's statements regarding his symptoms, as well as the results of the April 2011 VA examination, all suggest that the Veteran's PTSD had worsened. The Veteran is competent to testify as to the severity of the symptomatology associated with his PTSD during the time period in question. See Jandreau, 492 F.3d 1372. His statements are presumed credible because his complaints of symptoms have been consistent in both his lay testimony and in what he reported to his treating providers in the medical evidence of record as well as confirmed by the VA examiner. The Veteran's statements provide competent and credible evidence of gross impairment in thought processes or communication; grossly inappropriate behavior at work; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disturbances in mood, near-continuous depression and anxiety, irritability, suicidal ideation, homicidal ideation, near-continuous panic attacks, compulsive rituals, sleep impairment, nightmares, and memory loss. Furthermore, the 2011 VA examiner indicated that the Veteran's symptoms had worsened to such a degree, particularly rage and suicidality, that he should no longer work. This is the first medical evidence showing an indication of total occupational impairment. Also, the fact that the examiner indicated that the Veteran was virtually totally social impaired due to the increasing frequency of his wife's departures and the decrease of his friends down to just two people was shown to be the beginning of the worst his social relationships have been in the medical record. This pattern of impairment appeared to continue until it was again confirmed in the Veteran's April 2012 VA examination. All of this evidence persuasively suggests that the Veteran's service-connected PTSD was manifested by more than just occupational and social impairment with deficiencies in most areas because his PTSD symptoms had become more persistent and had a more significant effect on his occupation and relationships. Rather, his disability picture due to the service-connected PTSD reflected total occupational and social impairment. Additionally, the medical records from the time period in question began to contain consistent and recurring reports of gross impairment in thought processes or communication; grossly inappropriate behavior at work; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disturbances in mood, near-continuous depression and anxiety, irritability, suicidal ideation, homicidal ideation, near-continuous panic attacks, compulsive rituals, sleep impairment, nightmares, and memory loss. All of these symptoms are either included in the list suggested by the Rating Schedule in assigning a 100 percent disability rating for PTSD or are consistent with symptoms of that level of impairment. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Thus, and after resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence more nearly approximates the criteria for a 100 percent disability rating effective as of April 27, 2011. 38 C.F.R. § 4.7; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extra-schedular Consideration Finally, the Board finds that the Veteran's PTSD does not warrant referral for extra-schedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extra-schedular disability rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular disability rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board finds that the evidence does not warrant referral of the Veteran's claim for extra-schedular consideration. The level of severity of the Veteran's PTSD is adequately contemplated by the applicable diagnostic criteria. The criteria provide for a higher rating, but as has been thoroughly discussed above, the rating assigned herein is appropriate. The service-connected PTSD is manifested by signs and symptoms such as occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: difficulty in adapting to stressful circumstances (including work or a work like setting), disturbances in mood, near-continuous depression and anxiety, irritability, suicidal ideation, homicidal ideation, near-continuous panic attacks, compulsive rituals, sleep impairment, nightmares, and memory loss. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to mental disabilities provide disability ratings on the basis of the occupational and social impairment caused by a wide, yet not exhaustive, list of psychiatric symptoms . See 38 C.F.R. § 4.130, Diagnostic Code 9411. As such, the schedular criteria for mental disabilities contemplate a wide variety of manifestations of occupational and social impairment. Given the variety of ways in which the rating schedule contemplates occupational and social impairment of mental disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested by occupational and social impairment with deficiencies in most areas. In short, there is nothing exceptional or unusual about the Veteran's PTSD disability during the time period in question because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. Moreover, as a result of this decision, the PTSD has been awarded an increased disability rating of 100 percent effective as of April 27, 2011. In view of the adequacy of the disability rating assigned under the applicable diagnostic criteria, consideration of the second step under Thun is not for application in this case. Accordingly, the claim will not be referred for extra-schedular consideration. ORDER An initial disability rating in excess of 70 percent for service-connected PTSD prior to April 27, 2011, is denied. A 100 percent disability rating for service-connected PTSD, from April 27, 2011, is granted, subject to the applicable criteria governing the payment of monetary benefits. ____________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs