Citation Nr: 1415539 Decision Date: 04/09/14 Archive Date: 04/15/14 DOCKET NO. 09-34 540 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Casey, Associate Counsel INTRODUCTION The Veteran served on active duty service from August 1997 to August 2001 and from August 2006 to November 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). A notice of disagreement was received in July 2009, a statement of the case was issued in July 2009, and a substantive appeal was received in September 2009. FINDINGS OF FACT 1. Prior to December 11, 2008, it is not shown that the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity. 2. From December 11, 2008, to July 5, 2011, it is reasonably shown that his PTSD was productive of occupational and social impairment with deficiencies in most areas, such as work, family relations, thinking, and mood; total occupational and social impairment due to PTSD is not shown during that period. 3. From July 5, 2011, the Veteran's PTSD has been productive of no more than occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. Prior to December 11, 2008, a rating in excess of 30 percent for PTSD is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 2. From December 11, 2008, to July 5, 2011, a rating of 70 percent (and no more) for PTSD is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 3. From July 5, 2011, a rating of 50 percent (and no more) for PTSD is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Duty to Notify Upon receipt of a complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant pre-adjudication notice by letter dated in January 2008. The notification complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; and Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. The RO provided the appellant with additional notice in March 2009 and July 2009, subsequent to the initial adjudication. The notification complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and advised the Veteran of the laws regarding degrees of disability for PTSD. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 29 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist VA has obtained service records and VA treatment records, reviewed the Veteran's entire record, assisted the Veteran in obtaining evidence, and afforded the Veteran VA examinations in March 2008, March 2009, October 2009, and July 2011. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran and his representative have not contended otherwise. VA has complied with the notice and assistance requirements, and the Veteran is not prejudiced by a decision on the claim at this time. Legal Criteria and Factual Background The present appeal involves the Veteran's claim that the severity of his service-connected PTSD has increased, warranting a higher disability rating. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. Where there is a question as to which of two evaluations shall be applied, 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. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When evaluating the level of disability from a mental disorder, the rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). The rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). PTSD is evaluated under 38 C.F.R. § 4.130, Code 9411. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment from PTSD under 38 C.F.R. § 4.130 is not restricted to the symptoms in Code 9411. VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). PTSD is rated under the General Rating Formula for Mental Disorders. The Veteran's service-connected PTSD is currently assigned a 30 percent rating. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Code 9411. A 50 percent rating is warranted 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; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent 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. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." DSM-IV at 32. A score of 31 to 40 reflects some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood. A score of 41 to 50 is assigned where there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is appropriate where there are 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). A GAF score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. The Board has reviewed the Veteran's entire record with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. On March 2008 VA general examination, the Veteran reported difficulty falling asleep and staying asleep (sleeping only for about 3 hours), nightmares, feeling unrested, confusion, memory problems, slowness in thought, difficulty understanding directions, anxiety, one episode of a panic attack in July 2007, depression, detachment, loss of enjoyment in activities he previously enjoyed, irritability, and restlessness. The examiner noted that the course of his symptoms appeared stable; they were not worsening or improving. The Veteran had normal orientation, memory, behavior, comprehension, cognition, although the examiner noted that the Veteran did seem to compensate, using association to recall. May 2008 through February 2009 VA treatment records show that the Veteran reported that he failed a psychological test for a job as a police officer (a May 2008 notice letter of such is associated with his record), worked a full-time job at night, worked building his own house during the day, slept 2-3 hours per day, enjoyed spending time with other veterans, and that his job was going well. Treatment notes show that the Veteran was anticipating the birth of his child, was subsequently stressed about his child's illness and moving to his new home, and decided to not go visit his family for the holidays in the future due to his experiences as a child. The Veteran reported irritability, feeling angry, nightmares nightly, feeling vulnerable, difficulty relaxing, and difficulty with feeling confined. On May 2008 mental status examination, the Veteran was alert, oriented, cooperative, calm, dressed and groomed appropriately, and had a tired and slightly depressed affect, normal speech, organized and goal-directed conversation, intact insight, judgment, memory, and cognitive function. Hallucinations were not present. He denied suicide attempts, plan, or intent, and he was not an imminent threat to himself or others. In his February 2009 VA Form 9, the Veteran asserted that his PTSD had gotten worse and requested re-evaluation for PTSD. He stated that he did not sleep, had poor sleep quality, was hypervigilant and increasingly irritable, had become socially isolated, and had frequent intrusive thoughts of his experiences in Iraq. On March 2009 VA examination (which included a review of the Veteran's claims file and VA medical records), the Veteran reported flashbacks triggered by his son's crying, sleep deprivation, feeling distant from his wife and son, restricted range and affect, periods of dissociation during his child's birth, avoidance of friends, feeling uncomfortable around people, socializing with two other couples, loss of interest in outdoor activities he used to enjoy, irritability and outbursts of anger, daily anxiety and intrusive memories, panic attacks lasting about 10 minutes and usually occurring before and during work, exaggerated startle response, difficulty concentrating, hypervigilance, full flashbacks twice a week, irritability, fatigue, diminished cognitive functioning, pessimism about the future, onset insomnia one night a week, and waking after only a few hours of sleep due to nightmares (about twice a week), being startled, fear, or sobbing. On mental status evaluation, the Veteran was oriented, casually dressed in disheveled clothes, restless, cooperative, guarded, sarcastic, and attentive. He had constricted affect; his thought content was pessimistic and ruminating; recent, remote, and immediate memory were normal; insight and judgment were intact; intelligence was average; impulse control was good; he had obsessive behavior in the form of anxiously organizing his tools; and his mood was anxious, depressed, and dysphoric. Inappropriate behavior, hallucinations, and homicidal or suicidal thoughts were not present. Regarding activities of daily living (ADLs), there was slight impairment of self-feeding; moderate impairment of shopping, driving and exercise; severe impairment of traveling and other recreational activities. Regarding occupational functioning, the examiner noted that the Veteran had difficulty following instructions and that fatigue interferes with rate and efficiency. The Veteran reported he was employed full-time and missed 4 weeks of work over the past 12-month period due to medical/family issues. The diagnosis was PTSD; a GAF score of 51 was assigned for "over the past year" based on frequent panic and flashbacks, social isolation, moderately impaired family functioning, and severely disordered sleep. The examiner opined that the Veteran had occupational and social impairment in thinking, family relations, work, and mood. March through July 2009 VA treatment records show that the Veteran reported improved work function due to switching from the night shift to the day shift but increasing irritability due to being around more people during the day, problems in his relationship with his wife due to his sleep impairment, and poor eating diet when he was under increased stress. He also reported nervousness, anxiety, nightmares, hypervigilance, insomnia, depression, and some short-term memory loss. A September 2009 VA mental health record shows that the Veteran experienced extreme panic/anxiety during an improvised explosive device (IED) drill for combat training with his National Guard unit, in which he began to re-experience the IED attack he experienced in service. The clinician noted that the Veteran continued to have elevated levels of anxiety, continued to socially isolate himself, showed a marked decrease in frustration tolerance, and reported that work and family life were good at times and bad at others. On October 2009 VA examination for post-concussion headaches, the Veteran reported difficulty staying asleep, low sex drive, feeling detached from his wife and child at times, mood swings, anxiety, depression, decreased attention, difficulty concentrating and with executive functions, feeling impulsive, irritability, restlessness, startle response to loud noise, hypervigilance, fumbling his words when speaking, and lack of interest in going to work, being around people, or socializing. Testing showed mild impairment of memory, attention, concentration, or executive functions. The Veteran was oriented, and his judgment was normal, social interaction was routinely inappropriate, and communication was only occasionally impaired. The Veteran reported that he had missed 3 weeks of work in the previous 12-month period due to anxiety, and that his wife managed his financial affairs due to his lack of organization. The diagnosis was mild traumatic brain injury. In an October 2009 letter from the Veteran's wife, she explained that the Veteran became more emotionally distant from her after returning from Iraq and became more tense and edgy. She described the Veteran's ongoing depression, headaches, sleep disturbance, nightmares, sleep walking, lack of interest in exercising, his "short fuse," angry outbursts, "ever changing moods," shaking and trembling when he gets "un-nerved," an incident when the Veteran became enraged and physically assaulted his best friend, his resentment toward his family, social isolation, hypervigilance, avoidance of crowds, lack of affection toward her, exaggerated startle response, and difficulty with attention and concentration. October and November 2009 VA treatment records show that the Veteran reported anxiety, depression, some mood instability, some isolation and detachment from others, sleep disturbance, insomnia, nightmares, ongoing intrusive memories, flashbacks that seemed to be improving, some guilt feelings, avoidance of triggering stimuli, decreased interest and motivation, increased irritability at times, considerable hypervigilance, and some short-term memory loss. The treating physician noted that the Veteran had not been tried on any medications to date. The Veteran was alert, oriented, and interactive. His mood was relatively neutral, affect was appropriate, insight and judgment was intact, and there was no indication of any disturbance of thought process, thought content, or cognition. He denied any hallucinations, thoughts of suicide or self-harm, and did not appear to represent a threat to himself or others. The diagnosis was PTSD; a GAF score of 68 was assigned. On January 2010 VA neuropsychological evaluation, the Veteran reported poor concentration and short-term memory, variable mood that was predominantly depressive, continued interest in hunting but a loss of interest in other activities that he previously enjoyed, and that he continued to drive but avoided night driving and tended to stick to back roads when he drove. On mental status evaluation, the Veteran was oriented, attentive, and dressed appropriately in casual clothing. His grooming and hygiene were good, social interaction was appropriate and spontaneous, mood was sometimes "on the low side" and sometimes irritable, affect was mildly irritable, vision and hearing seemed adequate, insight and judgment were good, speech was normal, speech content was well organized with no indications of disorganized thought process, delusions, paranoia, or hallucinations. He denied any history of suicidal attempts, homicidal ideation, or suicidal ideation, intent, and plan. He did not seem to present a threat to himself or others. On testing, the Veteran's profile suggested he maintained average speech and language abilities, attention and concentration, mental flexibility, visual-spatial, and intellectual abilities. Memory abilities were estimated in the low-average to average range. Although the Veteran's scores were generally in the average range, he demonstrated slightly restricted immediate attention span or memory span in which to register information. The examiner opined that the Veteran's depressive and PTSD symptoms were likely to negatively impact attention and may thus appear to negatively impact memory as well. The diagnosis was PTSD, chronic; a GAF of 65 was assigned. A June 2010 VA treatment record shows the Veteran was alert, oriented, engaged, and anxious. He showed no difficulties with attention, concentration, remote or recent memory, and his insight and judgment were good. The Veteran reported a history of violence and substances abuse, but no history or current homicidal and suicidal ideation, plan, or intent. Testing showed that the Veteran had chronic impulsivity, some recklessness, high level anxiety ("on the go, productive," high physiological arousal), difficulty sleeping, and was easily distracted (racing thoughts). The diagnosis was PTSD, chronic; a GAF score of 57 was assigned. An August 2010 VA medication review record shows that the Veteran reported that he was receiving treatment from a private therapist, had increased depression, worked regularly and attended school, and was "staying busy outside of school." The Veteran was alert, oriented, and interactive. His mood was relatively neutral, affect was appropriate, insight and judgment were intact, and there was no indication of any disturbance in thought process, thought content, or cognition. He did not appear to represent an imminent threat to himself or others. The diagnosis was PTSD; a GAF score of 60 was assigned. An August 2010 letter from S.O., a VA psychologist, states that the Veteran had substantially reduced functional ability due to poor attention, concentration, recent/short-term memory, lack of energy/drive/motivation, intense anxiety (panic attacks 2 or more times a week), depression, difficulty comprehending and carrying out complex tasks, insomnia, irritability, angry outbursts, hypervigilance, increasingly impaired judgment, episodic substance abuse (alcohol/cannabis), and poor interpersonal functioning. The psychologist explained that the Veteran had been involved in 2 incidents in the past 3 months where, while under the influence of alcohol/cannabis, he engaged in impulsive, reckless, and dangerous behaviors necessitating police intervention. In the most recent incident the Veteran was involved in a motor vehicle accident while driving under the influence, resulting in "unsalvageable damage to the vehicle, minor-moderate physical injuries to his person, and severe retraumatization and increase in distressing/debilitating symptoms of PTSD." The Veteran fled from the scene of the accident in order to reduce/eliminate psychological distress. The psychologist opined that the Veteran suffered from PTSD related to combat exposure with poor prognosis given the chronicity and severity of symptoms. Enclosures included with the letter included a list of behavioral health clinic appointments showing numerous appointments from December 2008 through July 2010. A November 2010 VA treatment record shows the Veteran reported that he had a flashback, thinking he was in an IED explosion, when he had a motor vehicle accident. On July 2011 VA examination (which included a review of the Veteran's claims file), the Veteran reported that he had been married to his current wife since 2005, had two children, and was currently enrolled in college courses studying social work. He also reported constant anxiety, panic attacks about 3 times a week and lasting 10-15 minutes, constant depression, angry outbursts, road rage, irritability, engaging in "self-talk" to control his irritability/road rage, substance abuse, difficulty falling asleep and staying asleep, sleep disturbance, nightmares on a nightly basis when he does not drink, intrusive thoughts on a daily basis, exacerbated startle response, social withdrawal, avoidance of stimuli associated with the military or his experiences in service, ennui, detachment from people, difficulty concentrating, difficulty going to the store when people are there, constantly checking all the doors, and intermittent suicidal and homicidal ideation. He denied assaultive behavior, suicide attempts, hallucinations (except for an occasion when he saw an M4 rifle out of the corner of his eye), recent flashbacks, and any significant problems with hypervigilance. On mental status examination, the Veteran was oriented, alert, cooperative, and responsive, and maintained appropriate eye contact. He exhibited some agitation and was very tense during the interview. The examiner noted that the Veteran was capable of maintaining his activities of daily living (ADLs). The examiner opined that the Veteran had reduced reliability and productivity due to PTSD and that his disability also affected his social competence in a negative manner. The examiner commented that it was difficult to assign specific symptoms to either PTSD or traumatic brain injury exclusively without resorting to mere speculation. The diagnosis was PTSD; a GAF score of 68 was assigned. On July 2011 VA examination for traumatic brain injury, the Veteran reported irritability, restlessness, depression, difficulty falling asleep and waking up, nightmares, mood swings, anxiety, startled response to loud sounds, frequently inappropriate social interaction, and angry outbursts. Reports of mild memory loss, and difficulty with attention, concentration, or executive functions (speed of information processing, goal setting, planning, organizing, etc.) were noted, but without objective evidence on testing. The Veteran also reported missing 2 weeks of work within the prior 12-month period due to headaches, anxiety, and depression. On July 2011 VA examination for joints, the Veteran reported missing 3 weeks of work within the prior 12-month period due to lower back pain, anxiety, and depression. Analysis The Veteran has been service connected for PTSD and assigned a 30 percent rating under 38 C.F.R. § 4.130, Code 9411, effective November 2007. In addition, the Veteran has been service connected for residuals of a traumatic brain injury (TBI), effective November 2007 [which was initially rated as concussion headaches, under 9304, until a December 2011 rating decision reevaluated such disability as residuals of TBI, under Code 8045]. The concussion headaches/TBI present a somewhat complicating factor for evaluating PTSD symptomatology, because it too effects the Veteran's cognitive and emotional/behavioral functioning. See 38 C.F.R. §§ 4.130, 4.124a, Codes 8045, 9411. The Veteran has undergone VA examinations to assess the severity of TBI, and where possible such symptomatology will be differentiated from that of PTSD. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. 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 conditions. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Prior to December 11, 2008 Prior to December 11, 2008, it is not shown that the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity. The March 2008 VA examination report and VA treatment records through December 2008 predominantly show symptoms that are more closely analogous to 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). The Veteran had anxiety, irritability, depression, sleep impairment due to insomnia and nightmares, reported that his most recent panic attack had been about 8 months prior to the VA examination, and reported that he missed about 4 weeks of work over the prior 12-month period due to medical/family issues. Such symptoms more closely align with the criteria for a 30 percent rating than a higher rating. The Veteran also reported disturbances of motivation and mood, such as feeling angry and vulnerable, and not being able to relax. Although these symptoms align with the criteria for a 50 percent rating, the effect of such symptoms on the Veteran's occupational and social impairment were productive of, at most, occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Notably, he was able to work full-time at night, work on building his own home during the day, and reported that his job was going well. Therefore, his PTSD symptoms are more closely analogous to the criteria for a rating of 30 percent than the criteria for a higher rating. While the Veteran also reported symptoms of cognitive impairment, the March 2008 VA examiner attributed such symptoms (in addition to his sleep impairment, anxiety, and mood disturbance noted above) to the Veteran's TBI; significantly, the examiner did not diagnose PTSD on that examination. Further, mental status evaluations and neurological assessments performed through March 2009 essentially found normal orientation, cognition, memory, behavior, and comprehension. Finally, the Board notes that the Veteran was assigned a separate rating for concussion headaches/TBI for that period. Accordingly, the Board finds that a rating in excess of 30 percent for PTSD prior to December 11, 2008, is not warranted. From December 11, 2008, through July 5, 2011 In his February 2009 VA Form 9, the Veteran asserted that his PTSD symptoms had increased and requested re-evaluation. His statements alone do not provide a clear picture of the impairment such symptoms had on his occupational and social functioning. However, it is reasonably shown that for the period from December 11, 2008, the Veteran's PTSD was productive of occupational and social impairment deficiencies in most areas. The March 2009 VA examination report shows that the Veteran had an increased level of occupational and social impairment related to difficulty coping with the stress of having a child, the child's subsequent illness, and spending the holidays with his family. The Veteran's PTSD exacerbated the stress from such events, resulting in occupational impairment due to difficulty following instructions and decreased rate and efficiency in his work. On March 2009 VA examination, many symptoms characteristic of a 70 percent rating were not found. For example, suicidal ideation was not present; obsessional rituals were noted as organizing his tools obsessively, but there was no indication that this impaired his occupational or social function; his speech was unremarkable; impulse control was good; he was oriented and casually dressed; and the examiner found no impairment in his grooming. However daily anxiety, frequent panic attacks, disheveled clothing, difficulty in adapting to the stress of his newborn child, difficulty in establishing and maintaining social relationships, and some impairment to ADLs were noted. The examiner opined that the Veteran had occupational and social impairment in thinking, family relations, work, and mood. The Board acknowledges that the March 2009 VA examiner assigned a GAF score of 51 for "over the past year," based on frequent panic and flashbacks, social isolation, moderately impaired family functioning, and severely disordered sleep. The assignment of a GAF score of 51 for "over the past year" appears inconsistent with the Veteran's reports in May 2008 VA treatment records; specifically, that the Veteran worked full-time at night, worked on building his own home during the day, reported that his job was going well, and enjoyed spending time with other Veterans. It is also inconsistent with the GAF score of 70 that is shown in a February 2009 VA treatment record. As the VA examiner did not provide a rationale explaining the timeframe of "over the past year," the Board finds that other evidence of record is more probative of when the Veteran's PTSD became productive of a higher degree of impairment. Specifically, VA treatment records from December 11, 2008, show that the Veteran began experiencing increased PTSD symptoms related to the birth and subsequent illness of his first child and to visiting his family for the holidays. Based on the December 11, 2008, VA treatment records and the March 2009 examiner's basis for the GAF score of 51, the Board finds that beginning December 11, 2008, the Veteran's PTSD more nearly approximated occupational and social impairment with deficiencies in most areas. From December 11, 2008, the Veteran's PTSD was productive of no more than occupational and social impairment with deficiencies in most areas. He did not have gross impairment in thought processes or communication, persistent delusions or hallucinations, memory loss of close relatives, his occupation, or his own name, and he was not disoriented to time or place. Neurological testing on October 2009 VA examination found mild impairment of memory, attention, and concentration, but the Veteran was oriented with normal judgment, and communication was only occasionally impaired. VA treatment records (and the January 2010 VA neurological evaluation) during this period show that the Veteran was oriented, had essentially normal speech, insight, judgment, and thought process and content, and showed no indications of disorganized thought process, delusions, or hallucinations. The October 2009 VA examination shows the Veteran's social interaction was routinely inappropriate; however, it does not show that his behavior was grossly inappropriate on those occasions. VA treatment records and the January 2010 VA examination report show that the Veteran denied suicidal attempts, homicidal ideation, or suicidal ideation. The October 2009 letter from the Veteran's wife and the August 2010 letter from S.O. show that the Veteran had on several occasions engaged in impulsive and reckless behavior that endangered himself and others. However, the Board finds that it did not result in total and occupational impairment. The Veteran reported on July 2011 VA examinations that he had missed 3 weeks of work over the prior year due in part to his PTSD. On July 2011 VA examinations, the Veteran had symptoms reflective of panic attacks several times a week, difficulty understanding complex commands, moderate impairment of memory, disturbances of motivation and mood, and difficulty in establishing and maintaining work and social relationships. Intermittent suicidal and homicidal ideation, constant anxiety and depression, impaired impulse control of angry outbursts were also noted. However, the Veteran did not have gross impairment in thought processes or communication, persistent delusions or hallucinations, memory loss of close relatives, his occupation, or his own name, and he was not disoriented to time or place. Further, the examiner opined that the Veteran had reduced reliability and productivity due to PTSD, and assigned a GAF score of 68 (indicative of some mild symptoms). Considering all the evidence of record, the Board finds that the Veteran's PTSD most closely reflects occupational and social impairment with deficiencies in most areas. From July 5, 2011 However, VA examinations conducted on July 5 and July 6 of 2011 show a significant improvement in PTSD symptomatology. Mental status examination showed him to be cooperative and responsive with appropriate eye contact. He was capable of maintaining his basic activities of daily living. It was noted that he was currently enrolled in school and had an acceptable relationship with his wife and two children. The Veteran reported that although he experiences intense anger, he did not become assaultive. Panic attacks three times a week were reported. The examiner rendered an opinion that the PTSD resulted in reduced reliability and productivity. Based on this evidence, the Board finds that a rating of 50 percent, but no higher, is warranted from July 5, 2011. The preponderance of the evidence is against a finding that the criteria for a 70 percent rating are met from this date. Extraschedular Consideration Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is, thus, found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. Comparing the Veteran's PTSD disability level (for each period set out above) to the applicable criteria, the Board finds that the degree of disability shown is encompassed by the rating schedule. This disability does not present an exceptional disability picture: the PTSD symptomatology (i.e., anxiety, panic attacks, sleep impairment, irritability, angry outbursts, social withdrawal, detachment from others, flashbacks, posing a danger to himself and others, etc.) is addressed by the rating schedule. His other symptoms of hypervigilance and anxiety when confined are contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. 436 (2002). Further, the symptoms of impaired memory, attention, concentration, judgment, and visual spatial orientation have been additionally rated as TBI. The schedular ratings assigned for each period (prior to December 11, 2008, from December 11, 2008, to July 5, 2011, and from July 5, 2011) are, therefore, adequate; referral of the claim for extraschedular consideration is not required. Finally, the record shows that the Veteran is employed full-time. Consequently, the matter of entitlement to a total disability rating based on individual unemployability is not raised in the context of the instant claim for increase. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Entitlement to a rating in excess of 30 percent for the Veteran's PTSD prior to December 11, 2008, is not warranted. To this extent, the appeal is denied. Entitlement to a rating of 70 percent (and no more) for the Veteran's PTSD from December 11, 2008, to July 5, 2011, is warranted. The appeal is granted to that extent, subject to laws and regulations governing payment of VA monetary benefits. Entitlement to a rating of 50 percent (and no more) for the Veteran's PTSD from July 5, 2011, is warranted. The appeal is granted to that extent, subject to laws and regulations governing payment of VA monetary benefits. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs