Citation Nr: 1416093 Decision Date: 04/10/14 Archive Date: 04/24/14 DOCKET NO. 11-19 756 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to increased ratings for posttraumatic stress disorder (PTSD), rated 30 percent prior to September 5, 2012 and 70 percent from that date. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD K. Hughes, Counsel INTRODUCTION The Veteran had active service from March 1951 to March 1953. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2010 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified at a Board videoconference hearing in March 2012. A transcript of this hearing is of record. This matter was remanded in June 2012 and September 2013 for further development. An interim, January 2014 rating decision, granted an increased rating for PTSD to 70 percent from September 5, 2012. As the maximum increased rating for PTSD has not been granted from the date of claim, this matter remains on appeal and has been characterized accordingly. As noted in the June 2012 and September 2013 Board remands, the Veteran also initiated an appeal of a denial of an increased rating for ankylosis of the left little finger, as documented in a November 2010 SOC. However, he did not perfect the appeal of that issue for Board review through submission of a timely substantive appeal. Also as noted in the June 2012 and September 2013 Board remands, the issue of an earlier effective date for service connection for PTSD has been raised by the record. (See March 2012 videoconference hearing transcript and May 2012 Written Brief Presentation.) In addition, in the May 2012 Written Brief Presentation, the Veteran's representative refers to "the 2009 denial for several claimed limb conditions" which was "clear and unmistakable error." These matters have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over these matters and they are, again, referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT 1. Prior to September 5, 2012, the Veteran's service-connected PTSD more nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; at no time is the PTSD shown to have been manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity. 2. From September 5, 2012, the Veteran's service-connected PTSD has been manifested by symptoms productive of occupational and social impairment with deficiencies in most areas; at no time is the PTSD shown to have been manifested by symptoms productive of total occupational and social impairment. CONCLUSIONS OF LAW 1. For the period prior to September 5, 2012, the criteria for a rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.130, Diagnostic Code (Code) 9411 (2013). 2. For the period from September 5, 2012, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), and implementing regulations, require VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not in the record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186 (2002). These notice requirements apply to all elements of a claim, including the degree and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). The Board also stresses that since the issue in this case (entitlement to assignment of a higher initial rating) is a downstream issue from that of service connection (for which a VCAA letter was duly sent in March 2010) another VCAA notice is not required. VAOPGCPREC 8-2003 (Dec. 22, 2003). It appears that the Court has also determined that the statutory scheme does not require another VCAA notice letter in a case such as this where the Veteran was furnished proper VCAA notice with regard to the claim of service connection itself. See Dingess v. Nicholson, 19 Vet. App. 473, 491 (2006). 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, 129 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). The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. The RO arranged for VA examinations in June 2010 and September 2012 (with addendum in November 2013) and obtained a medical advisory opinion in March 2013. The Board finds that those examinations and opinions, cumulatively, are adequate for rating purposes, as the examiners expressed familiarity with the history of the disability and conducted thorough examinations, noting all necessary findings. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The RO's actions have substantially complied with the June 2012 remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. The Veteran was also provided an opportunity to set forth his contentions during a March 2012 hearing before the undersigned. The Court has held that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board and that a Veterans Law Judge has a duty to explain fully the issues and a duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that at the March 2012 hearing the undersigned set forth the issues to be discussed, focused on the elements necessary to substantiate the claim, and sought to identify any further development that was required to help substantiate the claims. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. Notably, in his July 2011 substantive appeal (VA Form 9, Appeal to Board of Veterans' Appeals), the Veteran claimed that he should have a rating of 70 percent. In the November 2011 VA Form 646, Statement of Accredited Representative in Appealed Case, the representative stated that the Veteran's symptoms most closely approximate the criteria for a 50 percent rating and, if granted, the Veteran would withdraw his appeal. Thereafter, in the May 2012 Written Brief Presentation, the Veteran's representative stated that the Veteran displayed several symptoms to support a 50 percent rating and his having no close friends supports a 70 percent rating. While a claimant is generally presumed to be seeking the maximum benefit available by law, he can choose to limit his claim to a lesser benefit. AB v. Brown, 6 Vet. App. 35 (1993). As a 70 percent rating from September 5, 2012 has been granted, the Veteran has been awarded a full grant of the benefit sought from that date September 5, 2012. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, and in Virtual VA, 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. In general, disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity caused by a given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part IV. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). In a claim for increase of an initial rating assigned with an award of service connection (as here), all of the evidence pertaining to the entire time period is to be considered, and staged ratings may be assigned for specific periods of time, as warranted based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). PTSD is rated under 38 C.F.R. § 4.130, Code 9411. The psychiatric symptoms listed in the rating criteria below are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the general rating formula for mental disorders a 30 percent disability evaluation is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is 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. 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. 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 or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9411. The Veteran has been assigned various Global Assessment of Functioning (GAF) scores for his PTSD. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect 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 other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Lesser scores reflect increasingly severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association : DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes]. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 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). When evaluating the level of disability from a mental disorder, 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). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. 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). The evidence of record reveals psychiatric diagnoses other than PTSD (depression and cognitive disorder). Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). In reviewing the claim, the Board notes that the evidence covering the period under review consists of VA clinical records, June 2010 and September 2012 (with November 2013 addendum) VA examination reports, a March 2013 medical advisory opinion and the Veteran's allegations of increased disability. VA treatment records show that the Veteran sought to establish care in May 2010. He complained of flashbacks from Korea. The assessment was PTSD with depression and anxiety and he was referred to the mental health clinic. On June 2010 psychiatry assessment the Veteran reported symptoms of flashbacks twice per month, nightmares once per month, depression, decreased energy and sleep, and feeling anxious and on edge. On mental status examination, he was alert and oriented to 4, cooperative and made good eye contact, exhibited good grooming and hygiene, psychomotor activity was WNL (within normal limits), speech had normal rate, volume and prosidy, cognition was grossly intact, and thought process was coherent and goal directed. The Veteran had no delusions or hallucinations and denied suicidal and homicidal ideations. His mood was slightly depressed and affect was appropriate. The diagnosis was PTSD and a GAF score of 55 was assigned. A subsequent June 2010 psychiatric assessment notes that the Veteran complained of feeling hopeless and helpless, guilty and worthless, and having episodes of tearfulness. The diagnosis was PTSD with dysthymia, anxiety and a GAF score of 51 was assigned. In July 2010, the Veteran rated his anxiety level at 8 or 9 on a scale of 1 to 10 (10 being the worst) and reported averaging 4-5 hours of disrupted sleep. A GAF score of 55 was assigned. On June 2010 VA examination, the Veteran reported being married twice, from 1959 to 1970 and from 1981 to the present. He reported current psychosocial stressors of having to raise his adolescent niece and nephew and worrying about his adult son. The Veteran retired in 1994, after working with the Ford Motor Company for 28 years. He stated that he has been depressed consistently since his deployment to Korea and has always been irritable, angry, had difficulty sleeping and experienced frequent flashbacks since discharge. The Veteran reported having no close friends other than a network of social acquaintances from church. The Veteran also reported a severe level of anxiety, markedly lost interest in in free time activities, feelings of detachment or estrangement and feeling as if his ability to experience a whole range of emotions has been somewhat curtailed. On examination, the Veteran was alert and oriented to all spheres, was neatly attired and appropriately groomed. Eye contact was good and mood and affect were unremarkable. The Veteran was cooperative, his thoughts were generally logical and well organized and his speech/thought content suggested no abnormality. He needed some time to process questions but there were no gross signs of cognitive impairment. Speech was at a normal rate but low volume. He reported no history of suicidal thought/intents. The examiner noted a mild-moderate level of depression with some symptoms of self-criticalness, changes in sleep pattern, self-dislike, agitation, loss of energy, fatigue and difficulty concentrating. Irritability or outbursts of anger and hypervigilance were also noted. The diagnosis was PTSD with associated depression. The examiner noted mild-moderate level of depression and mild-moderate level of anxiety related to PTSD. The GAF score was 55. VA treatment reports show continued mental health treatment in 2011 with GAF scores of 55 in May 2011, 51 in June and July 2011, 55 in September 2011 . Private treatment records show that the Veteran was involved in a car accident in October 2011 and, although he initially did well, in December 2011 his wife reported he had recently developed some speech problems that he could not understand, mild confusion, headaches and sleepiness. His computed tomography (CT) scan showed a very large isodense subdural hematoma in the left hemisphere from frontal to parietotemporal. He underwent a left craniotomy and evacuation of subdural hematoma in December 2011. A subsequent December 2011 treatment report notes the Veteran had had a stroke. January 2012 rehabilitation diagnoses were right hemiparesis, aphasia, dysarthria and dysphagia, all secondary to subdural hematoma/craniotomy, fluctuating mental status/encephalopathy. His fluctuating mental status was attributed to seizures, preexistent dementia and cerebral vasospasm. A January 2012 treatment report notes that speech therapy found the Veteran to be more aware of his surroundings, but he still had significant cognitive deficits. A March 2012 VA treatment report notes that the Veteran had been injured in a motor vehicle accident (MVA) in mid-October (2011) and started having headaches in December, his wife heard him say some words incorrectly, and he was treated in ICU (intensive care unit) for brain bleed (subdural hemorrhage (SDH)), trauma, step down and rehabilitation. On mental status examination, the Veteran was disoriented to time and place, had no ability to do serial 7's, was unable to write a sentence, and wrote numbers on the outside of a clock and put hands on the clock despite being asked to wait. He was aware of self and got 2 out of 3 items at one minute recall. The Veteran's thoughts were somewhat confused and he denied suicidal and homicidal ideation. His GAF score was 52. The examiner noted that the Veteran had an increase in anxiety and sleep and cognitive disturbance since the brain bleed. During his March 2012 videoconference hearing, it was argued that an increased rating for PTSD was warranted because he has cognitive and emotional impairment, irrational or impaired thinking, impaired judgment and increased nightmares. It was also reported that the Veteran has obsessive-compulsive behaviors, hypervigilance and panic attacks. The Veteran reported experiencing nightmares, intrusive thoughts, panic attacks, explosive anger, unprovoked irritability and difficulty coping with stressful situations. He also reported that his relationship with his family at home (his wife, son and adopted niece and nephew) sometimes get a little rough. He reported sleeping 3 to 4 hours per night. The Veteran reported not having much social interaction and preferring to stay at home by himself. He denied suicidal ideation. The Veteran's spouse also testified that his symptoms had become worse and he has problems speaking and expressing his emotions so that people understand him. She also reported that his short-term memory has become worse and he has become hyperactive (obsessive-compulsive). The Veteran's spouse testified that he becomes disoriented to time or place and forgets names. VA treatment records in April 2012 show Veteran's anxiety level was 9/10 and irritability was 10 on a scale of 1 to 10 (10 being the worst) and his GAF score remained 52. Later in April 2012, the Veteran continued to be depressed, slept 3-4 hours, and stated that he heard voices and saw things related to Korea. His mood was dysthymic, affect was sad and he was tearful. His GAF score declined to 45. An April 2012 neuropsychological evaluation report notes that, after his October 2011 MVA, the Veteran was hospitalized for headaches and confusion and was found to have a SDH which was thought to be related to the MVA. He underwent a craniotomy and evaluation of SDH and was reported to have limited insight and short term memory. The Veteran's neurocognitive test results revealed significant impairment in multiple cognitive domains encompassing function subserved primarily by the anterior/subcortical network. The executive planning functions were also significantly impaired in that he had severe difficulty effectively planning and executing an approach to a series of progressively more complex mazes. Secondary verbal memory was impaired, visuospatial memory was severely impaired and language functions were significantly impaired. In summary, the Veteran appeared to be grossly demented. May 2012 VA treatment records show continued dysthymic mood and sad affect with a GAF score of 51. On September 5, 2012 VA examination, the Veteran's psychiatric disorders were manifested by symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss (such as forgetting names, directions, or recent events); memory loss for names of close relatives, own occupation, or own name; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and suicidal ideation. PTSD and cognitive disorder were diagnosed and a GAF score of 50 was assigned. The examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood as a result of all his mental diagnoses. Further, the examiner noted that it is possible to differentiate what symptoms (and occupational and social impairment) are attributable to each diagnosis. Although all symptoms appeared by history (chronology) and interview to be related to the Veteran's PTSD, the memory and concentration issues could potentially be due to either PTSD or cognitive disorder NOS (not otherwise specified). The Veteran's appearance as "grossly demented" on April 2012 neuropsychological examination was more likely than not due to the cognitive disorder rather than PTSD. The examiner further noted that the finding of "previous MVA-related SDH" on the April 2012 neurological examination suggests a traumatic brain injury related to the MVA (which was resulting in the Veteran's memory and organizational difficulties.) Finally, the examiner explained that the Veteran was in a serious motor vehicle accident since the last VA examination in 2010 and the medical sequalae of the MVA appears to be implicated in the Veteran's current cognitive difficulties, based on the neuropsychological report summary. In an effort to separate the symptoms and occupational and social impairment due to the Veteran's service-connected PTSD and his non-service-connected psychiatric impairment, and, if the symptoms could not be separated, an explanation as to why separation is not possible, VA obtained a March 2013 expert medical advisory opinion. The medical expert reviewed the record (including VA electronic medical records) and opined that he is unable to differentiate or separate symptoms, and social and occupational impairment, due to the Veteran's service-connected PTSD and his non-service-connected subdural hemorrhage, status post MVA, without corroborating medical records from the hospitalization documenting his injuries and medical/surgical treatment, recovery and residuals, if any, from his MVA. The examiner explained that, without the MVA related hospitalization records, there are many questions (aside from suffering a SDH, was there loss of consciousness, pre or post MVA amnesia for events, neurosurgical intervention for subdural) but no information. Accordingly, the treatment records associated with the motor vehicle accident and an addendum opinion was obtained in November 2013. After review of the expanded record, in a November 2013 addendum to the September 2012 VA examination report, the examiner noted that the Veteran complained of concentration and memory issues at the time of his 2010 VA examination, which was prior to his motor vehicle accident. Thus, the examiner opined that all the symptoms noted (concentration and memory issues) are a result of the PTSD diagnosis. Upon consideration of the September 5, 2012 VA examination and November 2013 addendum, by a January 2014 rating decision, the RO granted an increased rating for PTSD to 70 percent from September 5, 2012. Prior to September 5, 2012 Addressing the staged ratings assigned for the Veteran's PTSD in turn, the Board notes that the reports of VA examinations and treatment records and the competent statements from the Veteran and his spouse prior to September 5, 2012, provide overall evidence against a rating in excess of 30 percent prior to September 5, 2012, as they do not show that symptoms of his PTSD produced occupational and social impairment with reduced reliability and productivity, so as to meet the criteria for the next higher, 50 percent, rating. During this period, VA treatment records and examination reports show that the Veteran had unremarkable speech, cognition was grossly intact, and thought process was was coherent and goal directed. Although his mood was slightly depressed his affect was appropriate. He had been married to his second wife since 1981 and had a network of social acquaintances from church (he reported not having any close friends). Although the record shows that the Veteran began having significant cognitive deficits and problems speaking and expressing his emotions so that people understand him, these symptoms developed after an October 2011 motor vehicle accident and have been attributed to his cognitive disorder as a result of the motor vehicle accident. Prior to the accident, the symptoms were more in keeping with the type of symptoms set forth as examples for a rating of 30 percent. The June 2010 examination showed the PTSD impairment to be in the mild to moderate range. The Board notes the GAF score of 45 assigned on April 2012 VA mental health treatment. However, that score is unexplained and is after his October 2011 motor vehicle accident and resulting cognitive disorder and, in light of the overall evidence, may not reasonably be found dispositive. In summary, it is not shown that prior to September 5, 2012, the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity, or that since that date it has been manifested by symptoms productive of deficiencies in most areas (or approximating such level of severity). Consequently, an increased rating in excess of 30 percent prior to September 5, 2012, is not warranted. From September 5, 2012 From September 5, 2012 (the date of a VA PTSD examination report when symptoms warranting such rating were first shown in the record) the Veteran's PTSD has been assigned a 70 percent rating. Consequently, what remains for consideration for this period is entitlement to a 100 percent rating. On review of the factual evidence since September 5, 2012, Board finds that at no time were symptoms of the Veteran's PTSD, alone, of (or approximating) such nature and gravity as to warrant a 100 percent rating. At no time during the appeal period is it shown that the Veteran had total occupational and social impairment, due to such PTSD symptoms as: persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting himself 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, or other symptoms of similar gravity; no such symptoms have been shown. Notably, although the record shows the Veteran to have significant cognitive deficits, his cognitive disorder has been attributed to the injuries sustained in the October 2011 motor vehicle accident, not to his PTSD. Consequently, the Board finds that criteria for a 100 percent rating are not met or approximated for any period of time under consideration. The Board notes the lay statements by the Veteran and his wife in support of this claim. Those statements detail the types of problems that result from the Veteran's PTSD symptoms and the levels of functional impairment described are consistent with (and do not exceed) the criteria for a 30 percent rating prior to September 5, 2012 and a 70 percent rating from that date to the present. As noted above, in his July 2011 substantive appeal (VA Form 9, Appeal to Board of Veterans' Appeals), the Veteran claimed that he should have a rating of 70 percent. Accordingly, because a 70 percent rating from September 5, 2012 is assigned, this is considered to be a full grant of the benefits being sought on appeal from September 5, 2012. See AB v. Brown, 6 Vet. App. 35, 39 (1993). Regardless, as discussed above, the Board did consider whether a higher rating could be granted, and found it could not. Furthermore, the Board finds that the evidentiary record presents no reason to refer the case to the Compensation and Pension Service for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b). There is no evidence of symptoms or impairment not encompassed by the schedular criteria, so as to render those criteria inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the Board is unable to find that a claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) based on his service-connected PTSD is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). ORDER The appeal seeking increases in the staged ratings (of 30 percent prior to September 5, 2012 and 70 percent from that date) assigned for the Veteran's PTSD is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs