Citation Nr: 1429280 Decision Date: 06/27/14 Archive Date: 07/03/14 DOCKET NO. 09-21 212 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to an increased disability rating (evaluation) for the service-connected posttraumatic stress disorder (PTSD), in excess of 50 percent for the period from April 7, 2003, and in excess of 70 percent from April 4, 2007. REPRESENTATION Veteran represented by: Robert V. Chisholm, Attorney ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from August 1969 to September 1971. This appeal comes to the Board of Veterans' Appeals (Board) from July 2007 and December 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In the July 2007 rating decision, the RO assigned a 50 percent disability rating for the service-connected PTSD from March 2, 2007 (the date of claim for the increased evaluation), to which the Veteran filed a timely notice of disagreement as to the effective date and disability rating assigned. The RO readjudicated the claim and, in the December 2009 rating decision, assigned a 50 percent disability rating effective April 7, 2003 (treating an initial behavioral health intake evaluation at a VA medical center (VAMC) as an informal increased rating claim) and a 70 percent disability rating from April 4, 2007, creating "staged" increased ratings. In a February 2013 Board decision, the Board, in pertinent part, denied an increased rating in excess of 50 percent prior to April 4, 2007 and in excess of 70 percent from April 4, 2007 for the service-connected PTSD. The Veteran appealed the Board's February 2013 decision to the U.S. Court of Appeals for Veterans Claims (Court). In October 2013, pursuant to a Joint Motion for Remand, the Court vacated the Board's February 2013 decision to the extent that it denied entitlement to an increased rating in excess of 50 percent from April 7, 2003 to April 4, 2007 and in excess of 70 percent from April 4, 2007 for PTSD. The parties to the Joint Motion for Remand specifically agreed that they did not wish the Court to disturb the remainder of the Board's decision as the Veteran was no longer pursuing an appeal of the remaining claims. The parties to the Joint Motion for Remand requested that the Court vacate the Board's decision on the basis that the Board had provided inadequate reasons and bases when denying the increased ratings. The parties agreed that the Board erred when it restricted its analysis to a discussion of the diagnostic criteria and the specific symptomatology the Veteran failed to display, as opposed to considering the impact of the Veteran's symptoms on his overall level of occupational and social impairment. The parties noted that the Board had failed to acknowledge or discuss a July 2010 private employability evaluation in which the examiner addressed the impact of PTSD on the Veteran's occupational functioning since 2003; did not adequately address the March 2011 VA examination report; and failed to adequately apply the Court's holding in Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Joint Motion for Remand instructed the Board to readjudicate the Veteran's increased rating claim and ensure compliance with Mauerhan. Where, as here, entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, including the appropriateness of staged ratings whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). As discussed below, the Board finds that the disability evaluations assigned by the RO did not adequately reflect the distinct time periods where the service-connected PTSD exhibited symptoms warranting different ratings. As such, the Board finds that the Veteran is entitled to a 70 percent disability rating for the period from April 7, 2003 to January 16, 2011 and a 100 percent disability rating from January 16, 2011 (the dates it is ascertainable the Veteran is entitled to higher ratings). In a July 2012 rating decision, the RO granted a total rating based on individual unemployability due to service-connected disability (TDIU) effective January 16, 2011 (the day after the Veteran's last day of employment). In October 2012, the Veteran filed a notice of disagreement seeking an earlier effective date for the grant of a TDIU contending that he had been working in sheltered employment since April 2003. A statement of the case was issued on May 20, 2014 and the Veteran has not yet perfected an appeal to the Board. As such, the issue of earlier effective date for TDIU is not currently in appellate status before the Board. A January 2013 private employability examination report has been received by VA and has been associated with the claims folder. While the most recent supplemental statement of the case, dated in August 2012, does not include review of this evidence, the Veteran, through the representative, submitted a waiver of agency of original jurisdiction (AOJ) consideration of the additional evidence. As such, the Board may consider the evidence in the first instance. In January 2010, the Veteran, through the representative, requested a Board videoconference hearing at the local RO, which was subsequently scheduled for November 2012. In correspondence received in November 2012, prior to the scheduled Board hearing, the Veteran's representative indicated that the Veteran wished to cancel the hearing and did not wish to reschedule. The request is deemed withdrawn and the Board may proceed with adjudication of the issue on appeal. 38 C.F.R. § 20.704(d) (2013). In reviewing this case, the Board has not only reviewed the Veteran's physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. For the rating period from April 7, 2003 to January 16, 2011, the Veteran's PTSD more nearly approximated occupational and social impairment, with deficiencies in most areas, due to such symptoms as: some suicidal ideation with vague plans, but no current intent; chronic sleep impairment, including nightmares; poor relationship with family and others; difficulty in adapting to stressful circumstances, including work; near continuous depression; impaired judgment; severe anxiety with panic feelings; difficulty with crowds; occasional homicidal ideation with no intent; impaired impulse control with unprovoked irritability and periods of violence; constricted and blunted affect; difficulty concentrating; and neglect of personal appearance and hygiene, including occasionally neglecting grooming habits. 2. For the rating period from April 7, 2003 to January 16, 2011, the Veteran's PTSD did not more nearly approximate total occupational and social impairment due to acquired psychiatric disorder signs and symptoms. 3. For the rating period from January 16, 2011, the Veteran's PTSD has more nearly approximated total occupational and social impairment manifested by intermittent inability to perform activities of daily living, including grooming and personal hygiene; complete inference with employment functioning, including inability to perform responsibilities required of him; lack of friends, social acquaintances, or relationships; anger management difficulties; depression; and anxiety. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, from April 7, 2003 to January 16, 2011, the criteria for an increased rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 2. Resolving reasonable doubt in favor of the Veteran, from January 16, 2011, the criteria for an increased schedular rating of 100 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the Veteran was provided notice in April 2007, prior to the initial adjudication of the claim in July 2007. The Veteran was notified of the evidence not of record that was necessary to substantiate the claims, VA and the Veteran's respective duties for obtaining evidence, and VA's practices in assigning disability evaluations and effective dates. Thus, the Board concludes that VA satisfied its duties to notify the Veteran. VA satisfied its duty to assist the Veteran in the development of the appeal. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file includes service treatment records, VA treatment records, private treatment records, Social Security Administration (SSA) disability records, VA examination reports, private employability and psychological evaluations, and lay statements. Second, VA satisfied its duty to obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran was provided with VA examinations in May 2007, March 2011, and June 2012 (the reports of which have been associated with the claims file). The Board finds that the VA examinations were thorough and adequate. The VA examiners personally interviewed and examined the Veteran, including eliciting a history, fully reviewed the evidence of record, conducted a mental examination, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic codes. The Veteran was offered the opportunity to testify at a Board hearing, but withdrew the hearing request in November 2012. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Increased Ratings for PTSD Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2013). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2013). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (2013). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. When, after careful consideration of the evidence, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where, as here, entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, including the appropriateness of staged ratings whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Francisco, 7 Vet. App. at 58; Hart, 21 Vet. App. 505. The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board has considered whether a staged rating is warranted and assigned a staged rating of 70 percent for the period prior to January 16, 2011 and a rating of 100 percent from January 16, 2011. On appeal to the Board, the Veteran is in receipt of a 50 percent disability rating for the increased rating period from April 7, 2003 to April 4, 2007 and a 70 percent disability rating from April 4, 2007 for PTSD under Diagnostic Code 9411. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent disability rating is assigned for 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 that is 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); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned 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; and memory loss for names of close relatives, or for the veteran's own occupation or name. Id. In this decision, the Board considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has considered the symptoms indicated in the rating criteria as examples of symptoms "like or similar to" the Veteran's PTSD symptoms in determining the appropriate schedular rating assignment, and has not required the presence of a specified quantity of symptoms in the Rating Schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the U.S. Court of Appeals for the Federal Circuit (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." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and a veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2013). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Within the American Psychiatric Association 's DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th Edition (1994) (DSM IV), one factor for consideration is the Global Assessment Functioning (GAF) score, which is a scale ranging from 1 to 100 and reflecting "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). However, while the rating schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). DSM-IV at 46-47. GAF scores from 61 to 70 reflect some 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, with some meaningful interpersonal relationships. Id. GAF scores ranging from 51 to 60 reflect 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). Id. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). Id. GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). Id. The Board has reviewed all of the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the issues. Throughout the course of this appeal, the Veteran has contended that the service-connected PTSD is worse than the assigned 50 and 70 percent staged ratings contemplate. In a May 2007 claim, the Veteran reported difficulty sleeping, nightmares, and feeling stressed. In an October 2012 written statement, the Veteran reported that during his employment, he took unscheduled breaks in the locker room to collect himself two to three times per shift for years and was absent several days each month due to his service-connected disabilities. The Veteran stated that he would clock out early and go home without explanation or permission at least once per month in order to keep himself from hurting anyone. The Veteran contended that he stopped working due to irritability and conflicts with supervisors. In a November 2012 written statement, through the representative, the Veteran contended that he meets the criteria for a 70 percent disability evaluation from April 2003 as he had problems at work, few friends, a poor relationship with family, and a conflictive and abusive relationship with his then-girlfriend. The Veteran reported his judgment and thinking were consistently impaired and his mood routinely depressed. Rating from April 7, 2003 to January 16, 2011 After a review of all the evidence, lay and medical, the Board finds that, for the increased rating period from April 7, 2003 to January 16, 2011, the Veteran's PTSD has been manifested by occupational and social impairment, with deficiencies in most areas, and more nearly approximates the criteria for a 70 percent disability rating under Diagnostic Code 9411. An April 2003 VA behavioral health initial evaluation report notes that the Veteran reported diminished interest in activities that was nearly constant, depression, anxiety, and some trouble concentrating. A May 2003 VA treatment record notes that the Veteran reported decreased energy, interest in activities, and appetite, feelings of hopelessness, difficulty sleeping, including nightmares, relationship problems, and problems with fights at work. The Veteran reported occasional suicidal thoughts with vague plans, but no current intent, and no homicidal ideation. The treatment record notes that the Veteran was currently living with a long-term girlfriend, had few friends, and had a poor relationship with family. The treatment record notes that the Veteran's affect was tired and sad and he had paucity of speech. The VA psychiatrist assigned a GAF score of 50. A June 2003 VA treatment record notes that the Veteran reported difficulties at work and home, including disagreements with his wife about drinking, and that there had been times when he pushed his wife. The treatment record notes that the Veteran's mood was depressed; affect was constricted; thought process was circumstantial but redirectable; judgment was impaired; and insight was limited. A June 2003 VA psychiatric evaluation notes that the Veteran was living with his girlfriend. The VA doctor noted that the Veteran's affect was blunted but acceptably modulated with a modest range of not inappropriate display. The VA doctor assigned a GAF score of 38. April 2007 private treatment records note that the Veteran reported becoming involved in fights at work and homicidal ideation with no intent. The Veteran's mood was noted as anxious and depressed. The Veteran reported multiple angry interchanges at work that almost resulted in his dismissal. A September 2007 private treatment record notes that the Veteran's relationship with his significant other had ended. At a May 2007 VA examination, the Veteran reported significant sleep impairment with nightmares, hypervigilance, long periods of depression, difficulty with crowds, severe anxiety with panic feelings, and irritability, reporting he had the frequent desire to hit sometimes, became violent at times, and argued quite easily. The Veteran reported having little family or friend contact, with his only friend being his fiancé. The Veteran reported problems with people at work, including difficulty getting along with supervisors to the point that he wanted to bring a rifle to his job and hurt something, and that he was suspended from work for one month because he was preparing to "beat up" a supervisor. The Veteran reported ignoring his grooming habits at times, but that his fiancé helped him with this. The Veteran denied suicidal ideation, but endorsed a sense of a foreshortened future. The Veteran reported being depressed and withdrawn over the recent years, including missing time from work due to emotional problems. The May 2007 VA examiner noted that the Veteran was oriented in all three spheres and indicated that there no evidence of hallucinations or delusions. The VA examiner noted that the Veteran had a violate temper and occasional homicidal ideation. The VA examiner assigned a GAF score of 50 and stated that the Veteran had severe PTSD symptomatology. An April 2009 VA treatment record notes that the Veteran reported depression, isolation from others, trouble sleeping with nightmares, and aggressive tendencies, when he wanted to hurt others but did not. The Veteran denied suicidal ideation. A November 2009 private treatment record notes that the Veteran lived alone. The Veteran denied delusions but reported seeing a dark human-like figure out of the corner of his eye. A July 2010 private employability evaluation provided a retrospective evaluation of the impact of the Veteran's PTSD on his occupational functioning. The evaluation report notes that the Veteran reported that work was stressful as he does not like to be told what to do, he often becomes hostile, and had missed a lot of work. The private vocational rehabilitation specialist noted that the Veteran appeared to have a low tolerance for interpersonal interactions at work, with difficulties both with supervisors and coworkers; had been hostile towards and threatened coworkers; and had taken excessive time off of work due to emotional problems. The vocational rehabilitation specialist stated that the Veteran's employment was "sheltered employment" and opined, while acknowledging that the Veteran was working, that the Veteran's functional problems stemming from PTSD had prevented him from securing or following substantially gainful occupation since April 2003. A January 2014 private employability evaluation provided a retrospective evaluation of the impact of the Veteran's PTSD on his occupational functioning. The evaluation report notes that the Veteran reported symptoms of suspiciousness, inability to trust, frequent startle response, sleep impairment with nightmares, and an inability to get along with others in both work and social contexts. The Veteran reported moderately to markedly limited memory and understanding in terms of remembering locations, work-like procedures, and detailed instructions and moderately to markedly impaired concentration. The Veteran reported that he preferred not to communicate or interact with others and that he avoids any public or social interaction. The private rehabilitation counselor noted that the Veteran's service-connected disabilities, and in particular his PTSD, had significantly restricted his ability to maintain focus and productivity and caused an inability to interact with coworkers and the general public. The report notes that, for several years prior to his current unemployment, the Veteran was having difficulty with supervisors and getting into fights at work. The rehabilitation counselor opined that it is at least as likely as not that the Veteran's service-connected disabilities rendered him unable to obtain and maintain a substantially gainful occupation at least dating back to April 7, 2003. Based on the above, the Board finds that, for the rating period from April 7, 2003 to January 16, 2011, the Veteran's PTSD has been manifested by occupational and social impairment, with deficiencies in most areas, due to such symptoms as: some suicidal ideation with vague plans, but no current intent; chronic sleep impairment, including nightmares; poor relationship with family and others; difficulty in adapting to stressful circumstances, including work; near continuous depression; impaired judgment; severe anxiety with panic feelings; difficulty with crowds; occasional homicidal ideation with no intent; impaired impulse control with unprovoked irritability and periods of violence; constricted and blunted affect; difficulty concentrating; and neglect of personal appearance and hygiene, including occasionally neglecting grooming habits, which more nearly approximates the criteria for a 70 percent disability rating under Diagnostic Code 9411. 38 C.F.R. §§ 4.3, 4.7, 4.130. The Board has weighed and considered the GAF scores during the period from April 7, 2003 to January 16, 2011, specifically the scores of 50 assigned by a VA psychiatrist in May 2003 and the May 2007 VA examiner and the score of 38 assigned in June 2003. GAF scores ranging from 41 to 50 reflect serious symptoms or any serious impairment in social, occupational or school functioning and scores ranging from 31 to 40 reflect some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood. DSM-IV at 46-47. The Board finds that the Veteran's GAF scores, when read together with the other evidence of record, reflect that the Veteran experienced occupational and social impairment with deficiencies in most areas, more nearly approximating the criteria for a 70 percent disability rating under Diagnostic Code 9411 for rating period prior to January 16, 2011. 38 C.F.R. § 4.130. The Board also finds the weight of the lay and medical evidence demonstrates that the criteria for a disability rating of 100 percent have not been met or more nearly approximated for the rating period prior to January 16, 2011. The Board finds that the Veteran's PTSD has not more nearly approximated total occupational and social impairment during any part of the rating period prior to January 16, 2011. The evidence of record reflects that the Veteran had a girlfriend during this period, admittedly a dysfunctional relationship, and had a good relationship with his son. While the July 2010 and January 2014 private employability evaluations note that the Veteran had "sheltered employment" and opined that the functional problems stemming from the service-connected PTSD prevented him from securing or following a substantially gainful occupation since April 2003, review of the evidence of record reflects that the Veteran was working throughout this period. The Veteran had major occupational impairment manifested by difficulties and fights with coworkers and supervisors, needing to work alone and take breaks, taking leave and leaving work early, but he was able to work throughout this period with these accommodations. The Board finds that the "sheltered employment" the Veteran engaged in prior to January 16, 2011 did not arise to the level of "total" occupational impairment under the schedular rating criteria. The Board has considered the assertion of sheltered employment as some evidence on the question of whether there is total occupational impairment for this period; however, the assertion or proof of sheltered employment that meets the extraschedular TDIU standard of inability to obtain or maintain substantially gainful employment (38 C.F.R. § 4.16) does not, ipso facto, prove total occupational impairment under the schedular rating criteria (38 C.F.R. § 4.130). To the contrary, the contention and the proof of ability to engage in sheltered employment tends to show that the Veteran is not totally occupationally impaired as required for the schedular 100 percent disability rating under 38 C.F.R. § 4.130. The July 2010 and January 2014 private employability evaluations provide specific assessments of the level of occupational impairment due to the Veteran's PTSD (unable to obtain and maintain a substantially gainful occupation), and identify underlying symptomatology and impairments that cause the occupational impairment. The ultimate determination as to the level of occupational and social impairment is an adjudicative determination. The Board has considered the July 2010 and January 2014 private employability evaluations on this question, but in light of the weight of the evidence of record showing that the Veteran's symptoms more nearly approximate occupational and social impairment with deficiencies in most areas due to the PTSD for the rating period prior to January 16, 2011, the Board finds the July 2010 and January 2014 private employability evaluations overall assessments as to the degree of occupational impairment are of lesser probative value. Further, a 100 percent rating under Diagnostic Code 9411 requires total occupational and social impairment. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that for the rating period from April 7, 2003 to January 16, 2011 the Veteran's disability picture more nearly approximates the criteria for a 70 percent rating, based on symptoms and the degrees of social and occupational impairment. See 38 C.F.R. §§ 4.3, 4.7. Rating from January 16, 2011 After a review of all the evidence, lay and medical, the Board finds that, for the rating period from January 16, 2011, the Veteran's service-connected PTSD has been manifested by total occupational and social impairment, and more nearly approximates the criteria for a 100 percent disability rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. In a January 2011 letter, Dr. F.K. noted that the Veteran perceived his work environmental to be hostile with fights breaking out regularly. Dr. F.K. noted that the Veteran has been having relationship problems at work and home. In a February 2011 letter, Dr. J.T. noted that the Veteran has difficulties carrying out activities of daily living, concentration, and interpersonal relationship. Prints out of the Veteran's work schedule dated from January 2005 to February 2011, note that the Veteran took multiple days a month of both scheduled and unscheduled leave from his work and eventually stopped working entirely on January 15, 2011. At a March 2011 VA examination, the VA examiner diagnosed the Veteran with chronic, severe PTSD and assigned a GAF score of 32 indicating the Veteran had major impairment in several areas including work, family relations, thinking, and mood. The VA examiner noted that the Veteran's PTSD significantly interferes with normal daily functions. The Veteran reported that if he is able to shower and shave twice a week he considers this a success and requires an inordinate amount of motivation to go to the bathroom to take care of personal hygiene. The Veteran reported a period of time that he was unable to take care of things such as cooking and cleaning. The VA examiner noted that the PTSD significantly interferes with the Veteran's employment functioning, with the Veteran reporting significant conflict with coworkers as well as an inability to perform responsibilities required of him. The Veteran reported working seven to nine days out of the month and that he takes leave the rest of the days because he is unable to leave the house due to a combination of physical and emotional pain. The March 2011 VA examiner noted that the PTSD has a significant impact on the Veteran's social functioning, with the Veteran reporting that he does not have any friends or social acquaintances, prefers to keep to himself, and that, while he has been in significant relationships in the past, his interpersonal difficulties have resulted in termination of these relationships. The Veteran reported one meaningful relationship with his adult son. The Veteran reported mostly staying at home and keeping to himself for fear of lashing out at others. In a May 2011 SSA functional report, the Veteran's friend reported that the Veteran often seemed depressed and occasionally becomes aggressive with difficulty being around others because of his aggressiveness. At a June 2011 SSA clinical psychological disability evaluation, the Veteran reported nightmares, sleep impairment, hypervigilance, depression, anxiety, and anger management difficulties. The Veteran reported that he did not have any friends. When asked about auditory and visual hallucinations, the Veteran reported that the night prior to the evaluation he heard a woman's voice but was unsure if he was dreaming. The SSA physician assigned a GAF score of 59. A September 2011 SSA disability determination notes that the Veteran is disabled due to primary diagnoses of affective/mood disorders and a secondary diagnosis of anxiety disorder. The report notes severe impairment due, in part, to these disabilities and indicates that the Veteran had been unemployable due to his disabilities since January 2011. At the June 2012 VA examination, the Veteran reported that his tendency towards irritability, difficulty trusting others, and need to isolate had taken a significant toll on virtually all of his interpersonal relationships. The Veteran reported that, on rare occasions, he will go out with someone or is visited by a niece. The Veteran reported that he did not have much interaction with his son, spending most of his time alone in his home, and feeling very isolated. The Veteran reported times when he has significant difficulty getting out of bed or showering for days at a time. The Veteran reported sometimes hearing intermittent whispers, described as a "supernatural experience." The VA examiner noted that the Veteran appeared to maintain adequate reality contact. The Veteran reported sometimes thinking he saw something dark out of the corner of his eye. At a June 2012 VA examination, the VA examiner noted Axis I diagnoses of PTSD, depression, not otherwise specified (NOS), and cannabis dependence and indicated that it was not possible to differentiate what portion of each symptom is attributable to each diagnosis because the Veteran's PTSD and depression result in many overlapping symptoms that are linked. The VA examiner noted that the Veteran's depression and cannabis dependence were secondary to the PTSD. The examination report notes that the Veteran was not currently employed. The June 2012 VA examiner noted symptoms of depression, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, impaired impulse control, such as unprovoked irritability with periods of violence, and neglect of personal appearance and hygiene. The VA examiner assigned a GAF score of 35 based on major functional impairments in several areas and 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. The June 2012 VA examiner noted that the Veteran's PTSD appeared to have worsened since he stopped working in 2011. At a June 2011 SSA clinical psychological disability evaluation, the SSA physician assigned a GAF score of 59. GAF scores ranging from 51 to 60 reflect moderate symptoms or moderate difficulty in social, occupational, or school functioning. DSM-IV at 46-47. The Board finds that the June 2011 GAF score of 59 is not supported by the contemporaneous findings and is highly inconsistent with the Veteran's presentation during the course of this appeal. The general characterization of overall impairment due to psychiatric disorders suggested by the assignment of a GAF score of 59 is inconsistent with, and outweighed by, the more specific and detailed social and occupational impairment and symptoms the Veteran has actually experienced during the course of the appeal, as reflected in both lay reports and clinical findings of symptoms and degree of occupational and social impairment. Further, for the rest of the rating period from January 16, 2011, the Veteran's GAF scores have ranged from 32 to 35. GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood. Id. The Board finds that the Veteran's GAF scores, when read together with the other evidence of record, reflect that the Veteran experiences total occupational and social impairment for this period. The March 2011 and June 2012 VA examinations provide specific assessments of the level of occupational and social impairment due to the Veteran's PTSD (deficiencies in most areas) and identify underlying symptomatology and impairments that cause the occupational and social impairment. The ultimate determination as to the level of occupational and social impairment is an adjudicative determination. The Board has considered the VA examination reports assessments on this question, but in light of the weight of the evidence of record showing that the Veteran's symptoms more nearly approximate total occupational and social impairment due to the service-connected PTSD for the rating period from January 16, 2011, the Board finds that the March 2011 and June 2012 overall assessments are of lesser probative value. Based on the above, and resolving reasonable doubt in the Veteran's favor, the Board finds that, for the period from January 16, 2011, the Veteran's PTSD has been manifested intermittent inability to perform activities of daily living, including grooming and personal hygiene; complete inference with employment functioning, including inability to perform responsibilities required of him; lack of friends, social acquaintances, or relationships; anger management difficulties; depression; and anxiety, which causes total occupational and social impairment, and more nearly approximates the criteria for a 100 percent disability rating under Diagnostic Code 9411. 38 C.F.R. §§ 4.3, 4.7, 4.130. Extraschedular Considerations For the rating period from January 16, 2011, the assignment of a 100 percent rating represents a maximum benefit based on the disability ratings schedule. See 38 U.S.C.A. § 1155. An extraschedular rating under 38 C.F.R. § 3.321(b) cannot result in a greater benefit for the period from January 16, 2011; therefore, any consideration of this theory of entitlement is moot for the rating period from January 16, 2011. 38 U.S.C.A. § 7104 (West 2002) (no question of law or fact remaining for the Board to decide). Further, as noted above, the Veteran is in receipt of a TDIU from January 16, 2011 and the issue of entitlement to a TDIU prior to January 16, 2011 is not currently in appellate status before the Board. The Board has considered whether referral for an extraschedular evaluation would have been warranted for the PTSD for any part of the rating period prior to January 16, 2011. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, 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. Thun v. Peake, 22 Vet. App. 111 (2008). 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, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that, for the rating period prior to January 16, 2011, the symptomatology and impairment caused by the Veteran's PTSD are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provide for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has been manifested by suicidal ideation with vague plans, but no current intent; chronic sleep impairment, including nightmares; poor relationship with family and others; difficulty in adapting to stressful circumstances, including work; near continuous depression; impaired judgment; severe anxiety with panic feelings; difficulty with crowds; occasional homicidal ideation with no intent; impaired impulse control with unprovoked irritability and periods of violence; constricted and blunted affect; difficulty concentrating; and neglect of personal appearance and hygiene, including occasionally neglecting grooming habits. These symptoms and degree of social and occupational impairment are part of the schedular rating criteria. The level of occupational and social impairment is explicitly part of the schedular rating criteria. The GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan at 443. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the acquired psychiatric disorders, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1), for the period prior to January 16, 2011, are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An increased disability rating for PTSD of 70 percent, but no higher, for the period prior to January 16, 2011, and of 100 percent from January 16, 2011, is granted. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs