Citation Nr: 1421822 Decision Date: 05/14/14 Archive Date: 05/21/14 DOCKET NO. 10-24 541 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD), to include sleep disorder, startle response, nervous condition and loss of memory. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney at Law ATTORNEY FOR THE BOARD James G. Reinhart, Counsel INTRODUCTION The Veteran served on active duty from March 1952 to January 1955. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. In June 2012, the Board issued a decision in which it adjudicated the appeal presently before it. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). In August 2013, the Court granted an Amended Joint Motion for Remand (hereinafter, the August 2013 JMR) of the Veteran and the Secretary of Veterans' Affairs (the Parties). In so doing, the Court vacated the June 2012 decision and remanded the issue to the Board for action consistent with the terms of the August 2013 JMR. Evidence has been added to the record since the RO last considered the claim. That evidence is not pertinent to the issue before the Board as it is no more than evidence of ongoing treatment without change from previous treatment and examination findings. Therefore, the Board will proceed with the adjudication of the issue. 38 C.F.R. § 20.1304(c) (2013). Additionally, it is noted that the Veteran requested a personal hearing before the Board in his May 2010 substantive appeal. The Veteran withdrew the request in a March 2012 submission. The Board may proceed. 38 C.F.R. § 20.704(d) (2013). The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2002). It is further noted that the issue of entitlement to a total disability rating due to individual unemployability (TDIU) was previously before the Board in June 2012. At that time, the Board remanded the TDIU issue to the RO for further development. In a December 2013 letter addressed to the RO, the Veteran's representative understandably asked the RO to hold that issue at the RO pending adjudication of the issue presently before the Board or to forward the TDIU issue to the Board. There is no indication that the development has yet been completed and the RO has not returned the issue to the Board. The TDIU issue is therefore not presently before the Board (it was remanded in June 2012). In light of the Board's finding below, the request to hold the TDIU finding is moot. The RO should address the Board's remand of June 2012. 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). FINDINGS OF FACT 1. The Veteran's service-connected PTSD, with sleep disorder, startle response, nervous condition and loss of memory, has been not manifested by total occupational and social impairment or occupational and social impairment with deficiencies in most areas. 2. The schedular rating for the Veteran's service-connected disability is adequate CONCLUSION OF LAW The criteria for an initial evaluation greater than 50 percent for PTSD, with sleep disorder, startle response, nervous condition and loss of memory, have not been met for any period on appeal. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Parties agreed that in its previous adjudication the Board did not discuss relevant medical evidence in its analysis to provide an adequate statement of reasons and bases. The August 2013 JMR listed examples, as follows: For example, in December 2007, [name omitted], the Chief of PTSD Services at the Greater Los Angeles VA Healthcare System, wrote that Appellant's: "life has been gravely influenced by his PTSD. He lives an isolated life and has difficulties with all his interpersonal relationships because of his psychiatric problems. He is unable to work and is impaired in all aspects of his psychosocial functioning. Additionally, in April 2008, a VA examiner noted Appellant was "unable to establish and maintain effective work/school and social relationships" due to social isolation. Further, he found Appellant was unable to have effective family role functioning, and unable to enjoy recreational or leisurely pursuits. The examiner concluded that prognosis for Appellant's PTSD condition was "poor." Likewise, in an April 2010 letter, [the Chief of PTSD Services at the Greater Los Angeles VA Healthcare System] again wrote to VA and opined that Appellant "is unable to work and function in normal daily living." He stated that Appellant's PTSD "contributes to a marginal lifestyle and chronic dysfunctional living." He noted Appellant "lives an isolated and withdrawn life." While the Board discussed this evidence to some degree, it appears to dismiss the opinions of these examiners because they do not reflect symptoms listed in the criteria for higher disability ratings. The parties agree that, while the Board noted the criteria for a 70 percent rating and listed various symptoms that Appellant does and does not have, it did not adequately discuss the schedular requirements for a 70 percent rating under 38 C.F.R. § 4.130. As VA has stated, "[a]lthough certain symptoms must be present in order to establish the diagnosis of PTSD, as with other conditions it is not the symptoms, but their effects, that determine the level of impairment." 61 Fed.Reg. 52,695, 52,697 (Oct. 8, 1996). Here, the record contains statements from various treatment providers as to the effects of Appellant's symptomatology on his occupational and social functioning. Because the Board erred when it did not adequately discuss or analyze the evidence with respect to these crucial questions in the diagnostic code, remand is required for the Board to readjudicate the claim. See Gilbert v. Derwinski, 1 Vet. App. at 56-57; see also Mauerhan, supra. Finally, the parties also note that the Board rejected the GAF scores assigned by Appellant's VA treating physicians in favor of what it termed "the much higher scores in the 50's, indicative of moderate symptoms" appearing in "the VA examination reports." It appears that all of the GAF scores cited by the Board, however, came from VA examiners and only one score cited by the Board was in the higher 50s, i.e. the GAF score of 59 assigned by the VA contract examiner in 2010, and therefore indicative of moderate symptoms. All of the other scores were 50 or below, which indicate serious symptoms (41-50) or major impairment (40 and below) under the DSM schema. To the extent it relies on the evidence of GAF scores, the Board on remand should explain its consideration of the scores and their significance. The Board here provides a detailed discussion, in compliance with the JMR: Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2013). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2013). The Veteran's service-connected PTSD, with sleep disorder, startle response, nervous condition and loss of memory, is evaluated as 50 percent disabling under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 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). Under the provisions for rating psychiatric disorders, a 50 percent disability rating requires evidence of the following: 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. The criteria for a 70 percent rating are as follows: 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 criteria for a 100 percent rating are as follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Id. at 118. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116 Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). While not determinative, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). According to DSM-IV, a score of 61-70 illustrates "[s]ome mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." Id. A score of 51-60 represents "[m]oderate 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)." Id. A score of 41-50 illustrates "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A score of 31-40 represents "[s]ome impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school)." Id. In reviewing the claims file, the Board notes that the Veteran has not submitted lay descriptions of his symptoms other than what he reported to the VA examiners and noted in the examination reports. His original claim, statements in support of his claim, his notice of disagreement, and his VA Form 9 do not describe his symptoms in any significant way. At best, his September 2006 claim indicates that the Veteran's assertion that had sleep disturbance, claustrophobia, frequent bouts of anger, loss of memory, disorientation and startle response. The Veteran was seen for VA psychiatric care in August 2006 just prior to the filing of his underlying claim for service connection for PTSD. The Veteran had a history of depressive, anxious and paranoid symptoms. A cognitive evaluation through the memory disorders clinic determined that he did not have dementia. The Veteran's primary complaint at that time was fatigue, though he also endorsed feeling fearful, upset, and irritable. A geriatric psychiatry note indicates that the Veteran was well-groomed in casual attire, pleasant and cooperative with good eye contact. He had no agitation or retardation of psychomotor activity, his speech was spontaneous and fluent, his mood was fine, and his affect was labile, initially euthymic, becoming tearful when discussing memories from the war. The Veteran's thought processes were tangential at times but mostly circumstantial. His thought content was focused, without suicidal ideation, hallucinations, or psychotic features. He was alert and oriented times four. His insight and judgment were fair. VA afforded the Veteran a relevant examination in October 2007. At that time he reported that he lived alone, was able to drive, and that he recently started to go to VA for treatment and support groups. On mental status exam, the Veteran was alert and oriented times three. He was properly dressed and hygiene was good. There was no major disorder of speech. Thought processes were coherent, without tangentiality or looseness of associations. The Veteran sometimes became circumstantial. His affect was slightly constricted and his mood was depressed. He had no delusional thinking, hallucinations, or suicidal or homicidal ideations. Intellectual functioning, abstract thinking, memory for recent and remote events, comprehension, and his ability to do calculations were intact and average. Past medical history was significant for obesity, sleep apnea and diabetes mellitus, type 2. The Veteran was noted to perform activities of daily living including driving. He was found to have poor social interactions - becoming angry and irritable, and to avoid socialization. The Veteran was considered capable of managing his personal funds. His GAF score was 50 In support of his claim, the Veteran solicited a December 2007 letter from a licensed clinical social worker (LCSW) who is the Chief of the PTSD Services of the Greater LA VA Healthcare System. The letter indicates that the Veteran had been active in VA's outpatient PTSD outpatient program. The Veteran attended weekly group sessions and individual sessions as needed. This practitioner stated that the Veteran was very motivated in his PTSD treatment and overall rehabilitative efforts. In describing his symptoms and level of impairment, the practitioner provided the following (original all in upper case): I am writing to you in my capacity as Chief of PTSD Services at the Greater Los Angeles VA Healthcare System and on behalf of [the Veteran]. [The Veteran] is a 73yo Korean War combat Veteran who has been active in or comprehensive PTSD outpatient program. [The Veteran] participates in weekly group and as needed individual therapy to help him deal with his horrific experiences and memories from his extensive combat exposure. [The Veteran] presents with a significant level of chronic PTSD that continues to effect (sic) his current life-functioning. He presents with the classic PTSD symptom clusters of intrusiveness, denial, and hyper-alertness. [The Veteran's] life has been gravely influenced by his PTSD. He lives an isolated life and has difficulties with all his inter-personal relationships because of his psychiatric problems. He is unable to work and is impaired in all aspects of his psychosocial functioning. His GAF is not over 40. The Board fully addresses the probative weight of this letter along with other evidence later in this document. At this point, the Board must note that the letter focuses on facts that are not directly relevant to the rating assigned for his disability (a 50%, 70% or 100% rating). For example, that the experiences he had during service were horrific (which is not in dispute) and that he had extensive combat experience are not facts that go to assigning a disability rating. His military service to this country is not in question. As is demonstrated by the Veteran's behavior, as reported by the Veteran, the GAF score of 40 is not reflected elsewhere in documents signed by experts where the experts explicitly refer to facts reported by the Veteran himself. In reviewing this evidence the Board must find that this all goes to reducing the probative weight assigned to this letter as a whole. This medical professional, overall, is simply not providing evidence that the next higher criteria is met. Regarding the question that his is "unable to work", this would be addressed within the context of the TDIU claim which the Board remanded to the RO and was delayed by the actions of the JMR. The statement that he is "impaired in all aspects of his psychosocial functioning" and other statements of a similar nature are found to be of limited probative weight as they provide little reasons and bases for such broad statements, particularly in light of the Veteran's own statements regarding how he functions normally, which will be addressed below. It does not clearly indicate occupational and social impairment with deficiencies in most areas. In a February 2008 statement, the Veteran indicated that his condition was worsening, without further explanation. VA provided another relevant examination in April 2008. The examination was performed by a different examiner than the one who examined him in 2007. The examiner included several paragraphs of relevant history. As to a specific history for PTSD, the examiner indicated that the Veteran's current reported symptoms were nightmares, flashbacks, and re-experiencing the Korean War; that the symptoms occurred constantly and that the effect of the symptoms upon total daily functioning was social isolation. The Veteran reported trouble sleeping for 40 years. The examination report notes that the Veteran reported social isolation. The Veteran was single with no children. The report states that the Veteran had not received psychotherapy in the past year, and had not been admitted to a hospital or visited an emergency room for psychiatric reasons. The Veteran had a longstanding history of diabetes mellitus, type 2, and sleep apnea. It was also noted that he had not worked since 2004 for medical reasons including renal cell carcinoma. Mental status examination found the Veteran oriented within normal limits. Appearance, behavior and hygiene were appropriate. Affect and mood were normal. Communication and speech were within normal limits. The Veteran showed difficulty understanding complex commands. The Veteran had difficulty focusing due to severe fatigue. He reported that he had panic attacks once a week, including anxiety and shortness of breath. There was no suspiciousness, delusional history, or hallucination history and no observed delusion or hallucination. The Veteran did not have obsessional rituals. His thought processes were appropriate, judgment was not impaired, and abstract thinking was normal. His memory was within normal limits. Suicidal and homicidal ideation were absent. The Veteran was described as having severely impaired concentration. As to impairment due to PTSD, the examiner stated that the behavioral, cognitive, social, affective, or somatic symptoms attributable to PTSD were severely impaired concentration. In a remarks section, the examiner explained that the Veteran did not have difficulty performing functions of daily living. The examiner also explained that he is unable to establish and maintain effective work/school and social relationships because he is socially isolative and guarded. Additionally, the examiner found that the Veteran was unable to maintain effective family role functioning because he had poor relationships with family members, was unable to engage in recreationally or leisurely pursuits because he had no hobbies. Finally, the examiner stated that the Veteran had no difficulty understanding commands, and posed no threat of persistent danger or injury to self or others. The examiner assigned a GAF score of 50. The GAF score assigned by this examiner is consistent with the facts recited and, the Board must find, the report is in more objective language. By the Veteran's own report just a few months after the December 2007 letter, he had not attended individual therapy for a year. Thus, the December 2007 letter is written in a manner that tends to, at points, to overstate the severity of the Veteran's disability in the statement that he needed individual therapy to help him deal with his horrific experiences and memories, but then he appears to function well without it. The examination tends to show that his impairment is in his ability to concentrate. This symptom approximates the criteria for a 50 percent rating, but no higher. The symptoms that he has are not of like kind to those listed for ratings higher than 50 percent. Nor is the level of disability required by the higher ratings reflected in these examination results. October 2008 treatment notes, signed by the Veteran's treating psychiatrist, do not show a disability picture more severe than that accounted for by the 50 percent rating. The listed effects are flashbacks, isolativeness, rushes of pain related to triggers of war memories, and nightmares. The psychiatrist's stated impression was that the Veteran's PTSD had persistent and pervasive effects on his quality of life and on inhibiting his ability to adapt to changes in circumstances. The psychiatrist stated that he would summarize those opinions in a letter and that since the Veteran did not receive other active treatment in this clinic, no further treatment was planned. In a November 2008 letter, the psychiatrist provided the summary. He indicated that his summary was based on a record review and two detailed interviews with the Veteran. The letter consists of five paragraphs. In the first paragraph, the psychiatrist reported that the Veteran has multiple physical problems that limit activity, is followed in mental health services for his PTSD, is primarily under the care of the Chief of the PTSD Services of the Greater LA VA Healthcare System, is also seen in Outpatient Geriatric Psychiatry, and that the psychiatrist has been his attending physician since July 2008. The last paragraph is not substantive. The middle three paragraphs are as follows: The diagnosis of PTSD has been well documented in the record - - and I note that [name omitted] is in fact the head of PTSD programs at West LA. [The Veteran's] persistent symptoms include: flashbacks, isolativeness, rushes of panic related to war memories, nightmares. In addition to these symptoms, [the Veteran] has struggled with associated symptoms of depression over many years, a mood state that has at times been severely limiting. Unfortunately, [the Veteran's] depression, and his PTSD symptoms, have shown no response to different anti-depressant medications over the years. However, [the Veteran] has been committed to the outpatient PTSD therapy program under [the Chief of the PTSD Services'] supervision and care and reports some sustained benefit. These symptoms of PTSD and depression have persisted over many years. They have had pervasive and enduring effects on his life, with compromise of the capacity for many activities. [The Veteran's] professional and personal life (sic) have been constrained by his restricted social outreach and a level of fatigue and anergia that directly hampered his ability to function. At this time, [the Veteran's] disability is increased, both by his physical limitations, but also because the associated depression and low energy that are due to his residual PTSD symptoms aggravate the effects of those physical disabilities. Specific limitation in daily life include the ability to initiate and manage his personal and household responsibilities. Walking and other physical activity are limited. Concentration is impaired, as is the ability to focus and sustain effort, thereby hampering the full range of daily chores and responsibilities. That the Veteran has persistent symptoms of PTSD, is unresponsive to therapy, his PTSD has enduring effects, he has a constrained personal and professional life, and an impaired ability to function due to fatigue and anergia, are not findings that indicate that a higher rating is warranted. These are statements that his PTSD symptoms are compensable, to some degree, they are not statements indicating that his PTSD is compensable to greater than a 50 percent rating. They would also support the current evaluation, but not a finding of occupational and social impairment, with deficiencies in most areas. Simply stated, it is important for the Veteran to understand that if he did not have problems with his PTSD there would be no basis for a compensable evaluation, let alone a higher evaluation. The fact that PTSD has "persisted over many years" only supports continuing the PTSD finding, not providing the Veteran with more compensation. Impaired concentration and the other problems cited are well within a veteran who has a 30% disability evaluation for PTSD, let alone a 50% evaluation, let alone a higher rating. The report that the Veteran's PTSD affects his physical disabilities does not go to the severity of his PTSD. Nor is any rationale provided for this statement. Whether it is an argument for secondary service connection for aggravation of a physical disability by his service-connected PTSD has been considered, but this is found unlikely (it appears that, at best, the examiner is indicating the Veteran's PTSD causes depression with low energy, nothing more, something that would be taken into consideration with a 50 percent evaluation). The Veteran is represented by an experienced attorney and it is reasonable to assume that if the Veteran wishes to file a claim for secondary service connection or aggravation of a non-service connected physical condition he will inform the RO. At this time, based on this limited statement, the Board finds that this issue is simply not being raised by the record. September 2009 VA treatment records document that the Veteran had financial distress. The Veteran borrowed excessively on credit cards and was unable to figure out how to deal with the problem. He was seen by a social worker, who helped him assess his spending habits. The Veteran was very agitated during the session, but was able to remain in control. Although the Veteran was unable to formulate a plan or assess his spending on his own, he was appreciative of assistance. The Veteran was also seen by a psychiatrist. The Veteran reported that he was anxious, had fragmented sleep, but maintained hope. The Veteran had difficulty concentrating or sustaining effort at any task. He cited several sources of "hope" including having attended a Trump seminar. He reported that he had not had suicidal ideation or impulses. The psychiatrist noted that the Veteran continued to live in the same apartment that he rented 20 years before as a stop-gap. The Veteran was plethoric, talked rapidly and self-distracted. He was anxious and had limited concentration, but compared well with chart information. He had no psychosis. Social worker notes from September 2009 include that the veteran was extremely anxious and scattered and had missed the post PTSD group today as he had a GU appointment. The social worker noted that when he poured out his stressors he was nearly in a panic. She reported that he did not cook because planning, preparing meals and washing dishes was overwhelming for him so he ate out at restaurants three times per day. She stated that he was overwhelmed by his PTSD symptoms and was making irrational decisions that affected his financing and health. She reported that he worried about losing his house due to his financial troubles. She stated that he had all the qualifications for a 100 percent service connection rating and that she would make every effort to unravel his claim and get him the benefits that he deserved. This is signed by the social worker, as well as the aforementioned Chief of PTSD Services, and the Veteran's treating psychiatrist. Although the Board discusses this in more detail when it more fully explains the reasons and bases for its decision, at this point the Board notes that facts related in these notes and letter tend to show that a higher rating is not warranted. Importantly, the social worker's characterization of what symptoms and level of disability meets the requirements for a 100 percent rating, at least with the exception of a TDIU, bear little relationship to the regulatory criteria for such a rating. For example, she states the Veteran makes irrational decisions and it is clear from the letter that this includes, to the social worker, eating out three times per week (as opposed to eating at home and conserving finances). To characterize such behavior as approximating "grossly inappropriate behavior", or "inability to perform activities of daily living" such as minimal personal hygiene, is so inaccurate that it tends to lessen the weight assigned to the evidence, at least with regard to the severity of disability due to PTSD in this case. This is because it shows that the treating social workers mean something different when they refer to "total disability" than is meant by the applicable regulations under 100%. A February 2010 psychiatry note indicates that the Veteran was seen for a follow-up. The Veteran had recently had a medication adjustment. He had depressive symptoms, including dysphoria, worry, and low energy. The Veteran reported that ruminating about his finances and the affordability of his rent. He reported recently contacting a lawyer to help him deal with creditors. The Veteran had intermittent insomnia related to sleep apnea, nocturia and arthritic pain. He was neatly dressed and groomed, appearing his stated age. The Veteran had an anxious-dysphoric mood, mildly restricted affect, but no delusions or preoccupations. The Veteran's thought processes were circumstantial, his speech was normal for pace, prosody, and volume. His judgment was fair to poor. His cognition was grossly within normal limits. The Veteran reported that he continued to attend social functions, such as veterans service organizations. He claimed that he still felt lonely. The Veteran had some neighbors with whom he felt friendly but had not established ongoing relationships. This evidence tends to show that the Veteran is not nearly as socially isolated as the Chief of PTSD Services reports, and shows an ability to function. He attends social functions, had neighbors with whom he felt friendly (and the earlier social work note documented that he goes out to eat three times per day). The facts of this case do not reveal the picture of a completely isolated person, as the treating social workers have characterized him. It is also not a picture of total disability and inability to function, indeed, although worried and depressed with regard to his finances, he contacted a lawyer to help him address the problems and he was neatly dressed and groomed, indicating that he is capable of more maintaining more than minimal hygiene. It also does not suggest occupational and social impairment, with deficiencies in most areas. Instead, it suggests an individual capable of living alone and working on his difficulties both effectively and in an organized manner. A March 2010 treatment note signed by the Veteran's psychiatrist documents that the psychiatrist had examined records from 1954 and expressed an opinion that his anxiety symptoms were due to his military service. This is not probative of the rating to be assigned (the disability is clearly related to service). The Veteran obtained another letter, this from April 2010, from the Chief of PTSD services of the Greater LA VA Healthcare System in support of his claim. This practitioner stated as follows: I am writing to you in my capacity as Chief of PTSD Services at the Greater Los Angeles VA Healthcare System and on behalf of [The Veteran]. [The Veteran] is a 76yo Korean War combat Veteran who has been active in our comprehensive PTSD outpatient program. [The Veteran] participates in a weekly group therapy and as needed individual therapy to help him deal with his horrific and life-threatening experiences and combat memories. Additionally, [the Veteran] has worked with a VA psychiatrist [name omitted] on his significant and profound PTSD. The PTSD is so pervasive that it continues to influence all aspects of this veterans' functioning. This PTSD contributes to a marginal lifestyle and chronic dysfunctional living. He presents with the classic PTSD symptom clusters of intrusiveness, denial, and hyper-alertness. This veteran lives an isolated and withdrawn life. He experiences interpersonal relationship problems that lead to conflict and social phobia. [The Veteran] is unable to work and function in normal daily living. He is severely disabled and impaired and his current GAF is 40. [The Veteran] has worked hard in PTSD treatment but his prognosis is poor. This chronic PTSD completely disables him. The Board provides an analysis of this letter after listing evidence from the same time frame. At this point, the Board notes that the letter is very similar to the 2007 letter and the Board's analysis of that letter therefore applies to this letter. VA provided another relevant examination in August 2010. The examination was conducted by an examiner who had not been the examiner in either the 2007 or 2008 examinations. The Veteran was noted to have osteopenia, hypogonadism and erectile dysfunction, primary hypothyroidism euthyroid, hyperlipidemia, diabetes mellitus, type 2, hypertension, history of renal cell carcinoma status post nephrectomy, benign prostatic hypertrophy, osteoarthritis and left knee arthralgia, obesity and hemangioma in addition to his depression and PTSD symptoms. The Veteran was also noted to have sleep apnea, for which he had been using a CPAP machine every night. The Veteran reported having gone to psychotherapy treatment through VA since 2006. He reported individual treatment once every two to three months, weekly group sessions and that medication had been of some benefit. The Veteran reported that he stopped working due to kidney cancer (not PTSD). This report includes the Veteran's assertion that his mental symptoms impaired his life in that he stayed alone, was anxious, and was too tired to talk to anyone. On mental status exam, the Veteran was alert, cooperative, pleasant, relaxed, and not hostile or fearful. Appearance, behavior and hygiene were appropriate. He had no bizarre posturing, gait or mannerisms. The Veteran described his mood as "real worried", but did not appear depressed or anxious. He denied suicidal or homicidal intent or ideation, had fluent speech without pressure or retardation, had no loose associations or tangentiality, but did have circumstantiality of speech. He denied hallucinations, delusions, schneiderian symptoms, or other psychotic symptoms. The Veteran had no psychomotor retardation or excitability. He was oriented to person, time, place and purpose. Recent and remote memories were intact but his immediate recall was impaired. The Veteran's intelligence appeared average. The Veteran was able to perform serial sevens well without mistakes and without loss of concentration. He made one mistake on calculations. The Veteran had some impairment of abstract thinking, getting three of four similes. There was no bizarreness or personalization and he had good judgment and insight. All of these facts provide evidence against this claim. The Veteran reported that he lived alone, took care of his own grooming and hygiene, drove, shopped, but did not do much cooking as he did not like to eat alone. It was observed by the examiner that he was neat and clean. The Veteran claimed no hobbies. He reported that he had two friends back in his hometown that he called and he denied contact with other relatives or family. The Veteran described his ability to get along with others as variable, claiming he was pretty hard to get to know personally. The Veteran described his usual day by saying that that night he was going to an American Legion meeting. He spent quite a bit of time going back and forth to VA and that he had many medical appointments. The Veteran reported watching TV, going to church on the weekends, and going out to breakfast. The Veteran claimed that he could no longer work, explaining that the stress increased the anxiety and depression. The examiner assigned a GAF score of 59. This examination is found to be compelling evidence against assigning a higher rating for disability due to PTSD. This examination shows that the Veteran is not so socially isolated or disabled as the Chief of PTSD Services and other records have asserted. This is also shown by the February 2010 treatment records which includes his report that he had neighbors with whom he felt friendly. Many of the Veteran's own statements support this finding. More importantly, the examination shows that his symptoms do not approximate an inability to establish and maintain effective relationships but do approximate difficulty in establishing and maintaining effective relationships. This is show by the Veteran's own report. He reported plans to go to an American Legion meeting and that he had contact with his friends. His description of his ability to get along with others - that it is pretty hard to get to know personally - is not one of an inability to establish and maintain effective relationships, but, at most, of difficulty in doing so, nearly the definition of a 50% evaluation for PTSD. This is also evidence against a finding that he suffers from difficulty adapting to stressful circumstances. Although he reported that he could no longer work because the stress, apparently of work, increased his anxiety and depression, elsewhere it is well reported that he does not work because of physical disabilities. It is also noted that he does not indicate that his PTSD renders him occupationally impaired so much as that additional stress increases the severity of his symptoms. Furthermore, his report of frequent doctor's appointments, with no indication that he has been unable to adapt to attending such appointments tends to show that he is able to adapt to stressful circumstances. Hence, his symptoms are the symptoms associated with the 50 percent rating. Consistent with the Federal Circuit's explanation in Vazquez-Claudio, and the facts of that case, it would be improper to assign a higher rating for symptoms specifically listed in the criteria for a lower rating. Now the Board turns to a more in depth discussion of the evidence and why it preponderates against a finding that his disability approximates the criteria for a rating higher than 50 percent. It is the effect of symptoms either listed in the criteria for a given rating or similar in kind, degree, and frequency, of those listed symptoms, on a veteran's functioning that gives rise to assigning the rating. The letters provided by Chief of PTSD Services that the Veteran's "life is gravely influenced by his PTSD" that he is "severely disabled and impaired", that he has needed therapy to help him deal with "his horrific and life-threatening experiences", and that he has worked with a psychiatrist on his "significant and profound PTSD" supports the Board's reasonable characterization that the practioner's reports are not always focused on the nature and extent of the PTSD (whether a 70% or 100% rating should be granted). In this regard, it is important for the Veteran to understand that a veteran with a 30% evaluation for PTSD, or 50% evaluation for PTSD, would also be "gravely influenced by his PTSD" and that their PTSD would be both "significant and profound PTSD". Furthermore, the treating practitioner's statements that are expressed as showing a degree of disability are sometimes contradicted by the Veteran's own reports of his functioning. The Chief of PTSD Services' statements that the Veteran's "chronic PTSD completely disables him", that he is "unable to function in normal daily living" are inconsistent with the Veteran's reports documented in the August 2010 examination report that he goes to American Legion meetings, goes to numerous medical appointments, goes out to eat frequently, and other statements cited above. In fact, the Board finds that many of the Veteran's own statements (as cited above) provide evidence against this claim. Similarly, the September 2009 note that asserts that the Veteran meets the criteria for a 100 percent rating also reports that he eats out three times per day and managed to attend a GU appointment instead of the PTSD group appointment (not the actions of a person with a 100% rating for PTSD could normally undertake). Furthermore, in her report of his symptoms, the social worker stated that he was nearly in a panic when talking about stressors, not that he experienced a panic attack. Clearly, these statements show an inaccurate understanding of what the rating criteria that must be approximated to warrant a schedular 100 percent rating. The other descriptions are not of disability that approximates the criteria for higher than a 50 percent rating. Those descriptions are that his PTSD is pervasive and influences all aspects of his life, that he has interpersonal problems that lead to conflict and social functioning. These are vague statements that are contemplated by the 50 percent rating but do not give rise to a finding that his disability approximates the criteria for a higher rating. This analysis also applies to the letter from the Veteran's psychiatrist. That the symptoms have persisted over many years, are pervasive, have enduring effects, compromise his capacity for many activities, have hampered his ability to function, constrained his social outreach, and limited his ability to initiate and manage his personal and household responsibilities, are not descriptions that show that his disability picture approximates the criteria for higher than a 50 percent rating. Indeed, this report is not evidence that his PTSD approximates any particular criteria. There is no statement of the kind of symptoms due to his PTSD or the extent of impairment that results. In this regard, it is important to note that the issue of TDIU is not before the Board at this time, as it was remand by the Board, and action on the TDIU issue was delayed by the actions of the JMR. The more specific evidence from this letter, for example that his concentration is impaired and hampers his activities is not evidence that his PTSD approximates the criteria for higher than a 50 percent rating. In this regard, difficulty in concentrating and loss of focus, without more description as to the level of such concentration problems, is not a symptom that is of the kind and degree as those expressed in the 70 percent criteria (such as, for example only, obsessional rituals that interfere with routine activities, impaired impulse control, and near continuous panic or depression affecting the ability to function independently, appropriately, and effectively). The conflict in the GAF scores is a conflict between the scores referred to by one practitioner, the Chief of PTSD Services, as opposed to those provided by three different examiners. The Board assigns more probative weight to the scores assigned by the examiners for several reasons. First, the outlier is the score provided by the Chief of PTSD Services which draws into question its probative value for reasons cited above. Second, clear from the discussion above, the level of disability attached to that score is not reflected elsewhere in the clinical record. Third, the level of disability attached to that score is contradicted in many cases by the Veteran's own reports to the examiners. While the Veteran has trouble with relationships, the evidence shows that he has never lost the ability to interact successfully with others. The Veteran's independence speaks volumes about his level of impairment. The Board discounts the low GAF scores in light of the Veteran's actual performance of the activities of daily living and his regular routine, as clearly cited within the VA treatment reports. The Board finds that the Veteran does not have occupational and social impairment with deficiencies in most areas. As to impact on his work or school, the only evidence of impairment is the Veteran's statement that work increases anxiety. There are, however, no facts to support this speculation. As for family relations, the Veteran does not have a family on which to rely. The Veteran lived this way successfully for decades, so the absence of family in itself is not indicative of significant impairment. The Veteran has some impairment of judgment and thinking shown by the financial trouble described in his treatment records. As discussed, the Veteran was able to overcome this with assistance. Review of the claims file shows that the episode was unique, not recurring. The Veteran has not, and does not have, suicidal ideation, or obsessional rituals. The Veteran's speech is not intermittently illogical, obscure, or irrelevant. Although the Veteran appears to be depressed nearly continuously, he retains the ability to function independently, appropriately and effectively (this is clearly indicated within the VA treatment records). The evidence does not show that he has the symptoms listed in the 70 percent or 100 percent criteria or symptoms that are not listed but are of similar severity, frequency, and duration. The Veteran reports regularly attending weekly group therapy, veterans' service organization meetings, church, eats out with great frequency, and maintains contact with friends. The Board also notes that after his September 2009 financial distress, the Veteran sought out legal counsel independently. To the extent that these are stressful circumstances, the Veteran has persevered in the face of each. Indeed, the number of social interactions undercuts directly the Chief of PTSD Services statements that the Veteran is "isolated" and withdrawn and that he has social phobia. The Board concludes that a 70 percent rating is not warranted. In this regard, it is important for the Veteran to understand that a 50 percent evaluation, by definition, is indicative that his PTSD causes him many problems, as clearly noted within the VA treatment records and examination reports. The problems cited within the VA treatment records, including those records that would appear to indicate the Veteran is more than 50 percent disabled due to his PTSD, primarily cite problems in support of this finding that, in fact, do not support this finding, but instead support the 50 percent evaluation. In this regard, it is important to note that not all evidence in this case support the current 50 percent evaluation. It is also important for the Veteran to understand that the Board has reviewed his statements in great detail (particularly those he provided to VA examiners). While they clearly indicate that the Veteran has problems associated with his PTSD, these statements are found to provide highly probative factual evidence against the claim that a 70 percent evaluation is warranted. While the Veteran notes problems such as anxiety (a problem that a veteran with a 50 percent evaluation for PTSD would be expected to have), he also clearly notes a work history stopped by "kidney cancer", being in a relationship that ended in 1992 because his girlfriend died, and his most recent mental status examination was generally good for a 76 year old man, with little indications of impairment beyond a 50 percent evaluation caused by PTSD. The more detailed review of the record provides more detailed factual evidence against this claim (again, the Board notes that the TDIU issue was remanded by the Board in 2012, delayed by the JMR, and is not before the Board at this time). Similarly, the Board finds that the Veteran does not have total social and occupational impairment due to his service-connected PTSD. The Veteran's many evaluations, both his VA examinations in connection with this claim and the letters in support by his treatment providers, do not show that the Veteran has (for example) gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. The Veteran's own statements, overall, fully support this finding. To the contrary, the Veteran has been alert and oriented, aware of where he was, what he was doing, and an active participant in both treatment and in the evaluations process for this claim. The Veteran lives alone, possesses and drives a car, manages his funds (though appears to spend too much, as noted above), has appropriate behavior and performs activities of daily living without supervision. The Veteran has had difficulty in adaptability, shown by the financial quandary described above. Although the Veteran was not able to see through the problem on his own, he was able to execute a plan to remedy the situation independently when presented with one. The Veteran also interacts with the general public on a routine basis. The Veteran does not cook anything more complex than sandwiches and so eats out with great frequency. This requires emerging into and interacting with the public. There have been no reports of inappropriate behavior or problems associated with his public interactions, providing factual evidence against his claim of high probative weight. In light of the foregoing, the preponderance of the evidence is against a finding of total social and occupational impairment. A 100 percent rating is not warranted. As neither a 70 nor a 100 percent rating is warranted, the Board finds that the preponderance of the evidence is against the Veteran's claim on a schedular basis. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied on a schedular basis. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). The schedular evaluation for the Veteran's PTSD disability is not inadequate. The General Ratings Formula for Mental Disorders relies on criteria framed inclusively. The Board has relied on the Veteran's occupational and social functioning in all reported aspects. The Veteran had one of the listed symptoms suggested for a 70 percent rating, impairment of thinking, but such does not result in impairment of functioning in most areas and is outweighed by the remaining evidence. The Board is aware that the Veteran's representative has requested extraschedular consideration in the TDIU theory of the claim discussed below, but he has not presented argument as to how a schedular rating would be inadequate. The Veteran merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are "unusual" or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. Where entitlement to compensation 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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the possibility of staged ratings. The Board, however, concludes that the criteria for a rating in excess of 50 percent have at no time been met. Accordingly, staged ratings are inapplicable. As such, the Board finds that the preponderance of the evidence is against the Veteran's increased rating claim. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The issue of TDIU will be addressed by the RO and, if necessary, but not necessarily in the case of a grant, by the Board. Further delay of this central issue only hurts the Veteran. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claim for an increased initial rating. See eg. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159 (2013); When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Prior to initial adjudication of the Veteran's claim, the RO sent letters to the Veteran in December 2006 and March 2007 letters that fully satisfied the duty to notify. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The claims file reflects that the Veteran was granted Social Security Administration disability benefits in 1992. "The duty to assist is not boundless in its scope" and "not all medical records . . . or all [Social Security Administration] disability records must be sought-only those that are relevant to the [V]eteran's claim." Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010). The Veteran has not claimed that these records are relevant. The records would be dated fourteen years prior to the date of service connection. Given that the Veteran has not alleged that the records are relevant, that they would be significantly removed in time from the current claim and that substantial and adequate evidence describing the Veteran's present level of functioning, the Board finds that the duty to assist does not require remand to obtain recent SSA records and would only delay the adjudication of in the case of Veteran who is in his 70's. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). The RO provided the Veteran an appropriate VA examination most recently in 2010. The Veteran has not reported receiving any recent treatment specifically for this condition (other than at VA, records of which are in the file), and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disorder since he was last examined. 38 C.F.R. § 3.327(a). The examination report provides sufficient evidence to apply the ratings schedule and to determine that the schedular rating is adequate. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The 2010 VA examination report is thorough and supported by VA outpatient treatment records. The examination in this case is adequate upon which to base a decision. Again, remanding this case for another examination, in light of the number of examinations that have already been obtained, would only delay the adjudication of case of a Veteran who is in his 70's. Such a remand must be considered unwarranted within the full context of this case. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). ORDER The appeal is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs