Citation Nr: 1532066 Decision Date: 07/28/15 Archive Date: 08/05/15 DOCKET NO. 09-31 906 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Rocktashel, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1969 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which granted service connection for PTSD and assigned a 30 percent evaluation. In December 2012, the Board remanded this issue for further evidentiary development. The requested development was completed, and the case has now been returned to the Board for further appellate action. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims held that a total disability rating based on individual unemployability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. As of this writing, the issue has not been raised by the record or asserted by the Veteran. Although the record indicates that the Veteran is receiving Social Security Disability benefits, the disability is noted as being due to problems with his back. See February 2013 VA examination. Accordingly the issue will not be addressed in this decision. FINDINGS OF FACT 1. Until June 21, 2012, PTSD was productive of occupational and social impairment with reduced reliability and productivity; occupational and social impairment with deficiencies in most areas was not shown. 2. After June 21, 2012, PTSD was productive of no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. Until June 21, 2012, the criteria for a 50 percent evaluation of PTSD, but no higher, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2014). 2. After June 21, 2012, the criteria for an evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). The VCAA applies to the instant claim. VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). With respect to the duty to notify, the claim in this case arose in the context of the Veteran trying to establish his underlying entitlement to service connection. This since has been granted and he has appealed the "downstream" issue of the initial rating assigned for his disability. The Veteran's filing of a notice of disagreement as to the initial rating assigned does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3) (2014). Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Rather, the Veteran's appeal as to the evaluation assigned triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This was accomplished in a March 2008 letter and in a statement of the case issued in August 2009. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher evaluation. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In November 2008 and February 2013, VA afforded the Veteran relevant examinations with respect to the severity of his PTSD. The examiners reviewed the Veteran's claims file and considered the Veteran's reported history, examined the Veteran, described his disability in detail, and provided an analysis to support any conclusions. Therefore, the examinations are adequate and allow the Board to make an informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). Upon Board remand, VA provided the Veteran with the February 2013 VA examination referenced above. VA also associated VA treatment records from December 2009 through November 2012 with the claims file, and readjudicated the claim. Although the multiaxial evaluation in the examination report was incomplete, a GAF score was assigned. In view of the report's details and the history and symptoms described, the Board finds that the examination, and the other actions taken by VA upon remand, substantially comply with the Board's remand directives. See Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010) ("It is substantial compliance, not absolute compliance, that is required" under Stegall v. West) (citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999)). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. There is no additional evidence which needs to be obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Increased Evaluation for PTSD Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Although the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of a claimant's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The United States Court of Appeals for Veterans Claims has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). As discussed below, there are two stages applicable to this appeal period. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, separate evaluations for separate and distinct symptomatology may be assigned where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Additionally, if two evaluations are potentially applicable, the higher evaluation is assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's PTSD is evaluated under Diagnostic Code 9411. This Diagnostic Code addresses PTSD, however, all psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, a 30 percent rating requires a showing of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted 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. A 70 percent rating is warranted 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 intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2014). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF score of 61 to 70 indicates some mild symptomatology (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. 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work, child frequently beats up younger children, is defiant at home, and is failing in school). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2014). The record here shows that the Veteran underwent VA treatment for PTSD and depression as early as the 1990's. During the appeal period, a March 2008 VA psychiatry progress note reported that the Veteran continues with minor bouts of depression. The Veteran was noted as being quite talkative, without overt signs of mania. He denied depressive symptoms at that time. The mental status examination showed the Veteran was very gregarious, laughed loudly, and was generally quite pleasant and cooperative. He was casually dressed with seasonally appropriate clothing, and he was moderately groomed. His speech was normal. He was talkative and vociferous and had normal articulation. His mood was euthymic. His affect was congruent with mood. He had logical, linear, coherent, and goal-directed thought processes. His thought content was normal and he denied suicidal ideation, homicidal ideation and denied auditory and visual hallucinations. His judgment was good. His insight was fair. His attention and concentration were good. His cognition appeared intact with no obvious deficits noted. An April 2008 VA primary care note showed the Veteran was concerned about generalized weakness and lack of energy over the prior year. His clinical examination was normal except for some difficulty when walking on his toes. Clinically, he appeared very depressed and angry. He felt his mood was unrelated to his fatigue, however. The November 2008 VA PTSD examination noted that the Veteran's depression had been well managed for the prior few weeks. However, he reported that he was so depressed one month prior that he tried to get himself admitted. His energy was described as low. He stated that he felt unmotivated and useless when he was unable to find work. He denied being able to get any pleasure out of his life. He endorsed significant hopelessness and despair associated with his employment problems. He expressed a pessimistic view about people in general in that he expected people to be dishonest and manipulative. He admitted to experiencing periods of suicidal ideation without significant intent or plan. He stated that he spent time worrying about his employment and financial problems. The Veteran reported that his appetite comes and goes and that he recently lost a lot of weight. The Veteran endorsed a history of experiencing "high" periods every few days. During these high periods, he feels confident and happy and has a great deal of energy and productivity. The Veteran has not been hospitalized for manic episodes and denied experiencing severe manic symptoms at the time of the VA examination. The Veteran also reported a history of anxiety attacks on a regular basis, which have improved with medication. He identified feelings of failure as a significant cause for his anxiety attacks. He described the following symptoms as occurring during his anxiety attacks: the desire to withdraw, the inability to write his name, the inability to drive, and a feeling of being out of control. The examiner found that these symptoms do not reach the level of panic attacks. The Veteran reported good relationships with his several children. He emphasized that he had been a part of their lives despite the relationship problems that he had with their mothers. At the time, he was living with his elderly mother, who he described as one of his closest friends. The Veteran reported one close friendship, which was mainly due to the friend's tenacity. The Veteran reported that he was able to work well with people such as his patients and his customers in the truck driving industry. He denied a history of interpersonal violence. The Veteran reported that in the mid 1990's he went to work as a truck driver so that he could be an independent businessman. He eventually lost his truck and his home due to financial problems. He indicated that the trucking industry was very "deceitful." He reported that his work at the time of the examination was very sporadic, and that the economy was interfering with his ability to obtain work. When not working, he was spending his time sitting at home and worrying. The VA examiner opined that the Veteran's psychosocial functional status was moderately impaired. The psychological examination revealed that the Veteran was clean and appropriately and casually dressed. He got up to use the restroom a lot, and had difficulty answering questions directly. His speech was clear and coherent. His attitude toward the examiner was cooperative and attentive. His affect was appropriate. His mood was anxious and slightly tense. His attention was intact. He was orientated to person, place, and time. His thought process was rambling with a looseness of associations and tangentiality. His thought content contained suicidal ideation, rumination, and paranoid ideation. He denied delusions. He understood the outcome of his behavior. He was of average intelligence. He understood he has a problem. He reported sleep disturbances in that he was awakening in a sweat once every three to four days, with no awareness of having nightmares. The Veteran reported that he was getting four hours of sleep per night on average. He was experiencing initial insomnia and frequent waking. He denied hallucinations. He presented no inappropriate or obsessive/ritualistic behavior. He denied homicidal ideation. He endorsed a number of episodes of suicidal ideation and planning in his life. The examiner found he had good impulse control with no episodes of violence. He was able to maintain a minimum personal hygiene. There was moderate problem with driving and recreational activities. His remote and recent memory were normal. His immediate memory was mildly impaired and the Veteran reported some difficulty with getting distracted in the middle of tasks. The examiner reported that the Veteran re-experienced his PTSD trauma with recurrent and intrusive distressing recollections of the event, including images, thoughts, perception, and intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. He made efforts to avoid thoughts, feelings, or conversations associated with the trauma. He made efforts to avoid activities, places, or people that aroused recollections of the trauma. He had markedly diminished interest or participation in significant activities. He had feelings of detachment or estrangement from others. He had restricted range of affect, for example, he was unable to have loving feelings. He had difficulty falling or staying asleep, difficultly concentrating, and an exaggerated startle response. The disturbances were noted to cause clinically significant distress or impairment in social, occupational or other important areas of functioning. He reported being less able to initiate and maintain close friendships. He endorsed experiencing problems with emotional numbing such that it was difficult for him to feel love for others in the manner that he expects he should. He reported difficulty with being able to laugh or cry at the same things that other people do. His symptoms were noted to be chronic with only slight improvement in nightmares and flashbacks since the 1980's. A GAF score of 55 was assigned. In February 2009 VA psychiatric treatment, the Veteran reported that he was doing fine, however, he was misplacing his medication more frequently. He had less anxiety and was not getting as irritated as easily as before. He was able to resist issues that bothered him. He did not feel depressed. He noted that he was still driving for a living. The objective evaluation showed the Veteran to be calm, pleasant, well-developed, and well-nourished, with euthymic mood and appropriate affect but in no acute distress. He was dressed appropriately for the season and setting. His speech was normal in rate, rhythm, and volume. His cognition was intact. He denied suicidal and homicidal ideation and auditory and visual hallucinations. There was no evidence of psychosis. His insight was good and his judgment was intact. A GAF score of 65 was assigned. In VA treatment in May 2009, the Veteran reported only sleeping for three or four hours per night. He reported that his medication works for only a short period of time and he is awake during the middle of the night. He had shifts in mood, but not a frequent as before. He reported a lot of anxiety attacks when he comes to the hospital. He reported being more relaxed than usual at the time of the examination. He reported not driving a truck anymore due to the slump in the economy. The mental status examination at that time showed the Veteran to be calm, pleasant, well-developed and well-nourished, with euthymic mood and appropriate affect but in no acute distress. He was dressed appropriately for the season and setting. His speech was normal in rate, rhythm, and volume. His cognition was intact. He denied suicidal and homicidal ideation and auditory and visual hallucinations. There was no evidence of psychosis. His insight was good and his judgment was intact. A GAF score of 60 was assigned. June 2010 VA treatment records show the Veteran went back to work driving trucks after being unemployed for one and a half years. He reported driving 10 hour trips twice a week, after which he would be very tired. He was in a minor accident for which he was to go to court. He reported feeling like he has to work to prevent himself from being homeless. He expressed concerns over the amount of his pay and other financial concerns. He reported that his medications were effective and he was happy with them. He denied suicidal or homicidal ideation as well as auditory and visual hallucinations. The mental status examination revealed the Veteran to be calm, pleasant, well-developed, and well-nourished, with a euthymic mood and appropriate affect but in no acute distress. He was dressed appropriately for the season and setting. His speech was normal in rate, rhythm, and volume. His cognition was intact. He denied suicidal and homicidal ideation. There was no evidence of psychosis. His insight was good and his judgment was intact. A GAF score of 60 was assigned. The examiner remarked that the Veteran had an improvement in his mood since he went back to work, however, he continued to have anxiety regarding his ability to maintain a place of residence. The examiner opined that the Veteran would benefit from continued medication compliance. In January 2011 VA treatment records, it was noted that the Veteran had anxiety, depression, and insomnia but responded well to current treatment. A mental status examination showed the Veteran to be adequately groomed with adequate hygiene. He appeared his stated age. He was calm and cooperative, with appropriate behavior and good eye contact. His speech was normal in rate and volume with good articulation and a full, dynamic range. His mood was euthymic. His affect was congruent. He denied auditory, visual and "t" hallucinations and none were evident. His thought process was linear, logical and goal directed. There was no flight of ideas, and no looseness of associations. There were no suicidal or homicidal ideations. The Veteran denied delusions. His cognition was grossly intact. His insight was fair and his judgment was fair. A multiaxial assessment was reported, in which it was noted that the Veteran was "isolative." A GAF score of 55 was assigned. In February 2011 VA treatment records, the Veteran stated that he had been having a lot of mood swings. He reported feeling more depressed from the changes in the weather and not wanting to be involved in anything. He reported difficulty getting going and occasionally not wanting to take a bath. He wanted Depakote to be reinstated to his medication regimen since he felt it helped him in the past. The examiner noted a history of mania in the past lasting at least one day. The Veteran reported current high levels of anxiety. He reported that a core of medications are effective and help him to function. He stated that he was unaware that his symptoms of PTSD were present when he initially sought treatment. He requested a different sleep medication since his current one lasts only 4 hours. He reported not having as much energy as before and realized that he has serious limitations. He is adjusting to his actual age. He reported being more organized than before and more complaint to his medication treatment plan. The mental status examination revealed a middle-aged male who appeared calm, pleasant, well-developed, and well-nourished, with euthymic mood and affect, and in no acute distress. He was dressed appropriately for the season and setting. His speech was normal in rate, rhythm and volume. His cognition was intact. He denied suicidal and homicidal ideation. He denied auditory and visual hallucinations. There was no evidence of psychosis. His insight was good and his judgment was intact. The assessment was that there was some change in mood after being off of his medications for a significant period of time. He has been stabilized on his medications before and will benefit from being put back on them. He did not appear to be a threat to himself or to others. A GAF score of 60 was assigned. In August 2011 VA treatment records, the Veteran reported that he was doing well until he started to run out of medications. The Veteran reported that the medications are effective for him, and help him fall asleep and reduce some of his anger. He reported that his mood has been constant and he is not irritated by anything. He is able to handle his stress very well. He stated that in the past, he was prone to anxiety attacks. Currently, he gets anxious but he is still able to function. The anxiety occurs when he is under pressure. He asked to be restarted on a particular medication because it helped reduced his nightmares and allowed him to have a good night's rest. He denied the presence of suicidal or homicidal ideation as well as auditory and visual hallucinations. The mental status examination revealed a middle-aged male who appeared calm, pleasant, well-developed, and well-nourished, with euthymic mood and affect, and in no acute distress. He was dressed appropriately for the season and setting. His speech was normal in rate, rhythm and volume. His cognition was intact. He denied suicidal and homicidal ideation. He denied auditory and visual hallucinations. There was no evidence of psychosis. His insight was good and his judgment was intact. The assessment was that the Veteran was stable and would continue to benefit from medication adherence. He did not appear to be a threat to himself or to others. A GAF score of 60 was assigned. In January 2012 VA treatment records, the Veteran reported continuing to do "fine" although he was having occasional bouts of anxiety. He reported that his mood was otherwise stable and his sleep and appetite generally appeared to be good. He denied feeling depressed. He reported being compliant with his medication and he denied experiencing any adverse side effects. He denied suicidal and homicidal ideation. There was no evidence of mania or psychosis. The mental status examination revealed an older male who appeared calm, pleasant, well-developed, and well-nourished, with euthymic mood and affect, and in no acute distress. He was dressed appropriately for the season and setting. His speech was normal in rate, rhythm and volume. His cognition was intact. He denied suicidal and homicidal ideation. He denied auditory and visual hallucinations. There was no evidence of psychosis. His insight was good and his judgment was intact. The assessment was that the Veteran was stable. A GAF score of 65 was assigned. In March 2012 VA treatment, the Veteran reported dealing with everything in a good way. He stated that getting older with reduced strength was causing him to struggle emotionally. He had back surgery and this started to make him age, however, the back surgery helped him to feel better. He reported displeasure at being on social security and being at home and not working. He reported that he is isolated most days and this is new to him. He reported an increased abdominal girth since he started taking the medications. Also, he is sleeping more than before. He stated that he cut a lot of negativity from his life style and was dealing more with positive things in life. He denied the presence of auditory and visual hallucinations. The mental status examination revealed a middle-aged male who appeared calm, pleasant, well-developed, and well-nourished, with euthymic mood and affect, and in no acute distress. He was dressed appropriately for the season and setting. His speech was normal in rate, rhythm and volume. His cognition was intact. He denied suicidal and homicidal ideation. There was no evidence of psychosis. His insight was good and his judgment was intact. The assessment was that the Veteran was stable on current medications. He was dealing with the different stages of life and appeared to have some trouble adjusting to the period that he was then in. A GAF score of 60 was assigned. In June 2012 VA treatment, the Veteran reported his life was "going pretty good." He talked about the time when he used to have flashbacks and did not know what they were. He said he knows that it is easy to be sick and have no one notice it if the person is concealing his or her problems. He talked about the way his jobs influenced his four sons in their career paths. He was able to spend some time with his son in a bonding session recently. He talked about the difference between working with veterans and civilians to find out what triggered them to react the way they do. He denied the presence of suicidal or homicidal ideation as well as auditory and visual hallucinations. The mental status examination revealed a middle-aged male who appeared calm, pleasant, well-developed, and well-nourished, with euthymic mood and affect, and in no acute distress. He was dressed appropriately for the season and setting. His speech was normal in rate, rhythm and volume. His cognition was intact. He denied suicidal and homicidal ideation. There was no evidence of psychosis. His insight was good and his judgment was intact. The assessment was that the Veteran was stable and a GAF score of 60 was assigned. In November 2012 VA treatment, the Veteran stated that he was doing fairly well and stated that he had been working on a sleeping problem for a while. He reported that being a former trucker impacted his sleep habits and routine. He admitted that his sleep was variable and he no longer had a problem going to sleep. He admitted that he has not a lot to do as he retired from the trucking business in 2010. He admitted that his appetite had been quite good for the "number of calories that [he] burns." He denied having nightmares and states that he has not had them since he has been treated. He stated that he had not had flashbacks in quite some time. He denied manic or hypomanic symptoms. He denied paranoid delusions and visual and auditory hallucinations. He denied suicidal and homicidal ideations, and intent, plans and denied access to weapons. The associated mental status examination revealed that the Veteran appeared his stated age with fair personal hygiene and grooming. He was dressed appropriately for the cool weather. He was calm and cooperative. He was alert and oriented to person, place, time and purpose. His eye contact was limited. There was no psychomotor agitation or abnormal movements noted. His gait was balanced. His orientation was alert. His speech was clear, slightly raspy and loud, with a normal rate and volume, and it was fluid. His mood was "pretty good," and he noted that he mentally prepared himself for the appointment. His affect was euthymic. His immediate memory was 3/3. His recent memory was 3/3 and his remote memory was intact. His concentration and attention were good. He was able to perform serial subtractions of 3 from 20 with some difficulty. His abstract thinking was good. His thought process was logical and his thought content was appropriate. His insight was fair and his judgment was fair. A GAF score of 55 to 60 was assigned. The February 2013 VA examination report noted a current diagnosis of "Mood Disorder not otherwise specified." The examiner found that the Veteran's level of occupational and social impairment was best described as a mental condition which has been formally diagnosed, but the symptoms of which were not severe enough to interfere with occupational and social functioning or to require continuous medication. The Veteran reported that he was not working, and applied for disability following an operation on his back in 2011. The Veteran further reported that he had recently dealt with a family dispute, but continued to maintain a good relationship with his mother who visits twice per week. The examiner noted that the Veteran has six children by two different marriages. The report noted that medications were the same as the last examination. The examiner found the Veteran to have symptoms of depressed mood and anxiety. The examiner noted symptoms of difficulty falling or staying asleep and exaggerated startle response. The examiner found the Veteran's PTSD traumatic event not to be persistently reexperienced, and that the Veteran does not persistently avoid stimuli associated with the trauma or numbing of general responsiveness. The examiner further found that the Veteran presented with a stable mood and with no suicidal ideation or intent. The Veteran denied many symptoms at that time. The examiner noted that the Veteran denied that he faces any persistent challenges in his life. He reported that his medication has been generally effective and that his overall symptom presentation is much less than it was at an earlier time in his life. The Veteran reported some mood symptoms when pressed, but denied that his functioning was impaired. The examiner opined that there was no reason from a mental health standpoint that the Veteran would be unemployable. A GAF score of 80 was assigned. After a review of the evidence of record, the Board finds that an evaluation of 50 percent is warranted for PTSD until June 21, 2012, however, the current evaluation of 30 percent is warranted thereafter. In adjudicating appeals for disability evaluations, the Board must interpret various examination reports in light of the entire medical history, reconciling any contrary findings into a consistent picture. 38 C.F.R. § 4.2 (2014). In that regard, until June 21, 2012, a 50 percent rating is warranted as the Veteran demonstrated disturbances of motivation and mood, as well as significant sleep disturbances that were nearly constant. In November 2008, he experienced suicidal ideation, although without significant intent or plan. He endorsed significant hopelessness, despair, and emotional numbing. He also reported anxiety attacks on a regular basis. During anxiety attacks, he was unable to write his name and drive, and he experienced the desire to withdraw, and he had a feeling of being out of control. In January 2011, he was isolative. In February 2011, the Veteran experienced mood swings and some occasional lack of hygiene. In March 2012, the Veteran was improved, but reportedly struggling emotionally as he was adjusting to a new stage of life. The Board finds that these symptoms are shown to be more severe during this portion of the appeal period than occasional decrease in work efficiency. Thus, resolving reasonable doubt in favor of the Veteran, the Board finds that the disability picture more nearly approximates a 50 percent evaluation than a 30 percent evaluation. A higher 70 percent rating is not warranted during this period as the record does not demonstrate occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood. In fact, the Veteran endorsed a good relationship with his sons and his mother. In November 2008 VA examination, he reported that he was able to work well with people in his occupations. Moreover, he continued working throughout the period except when due to the economy and upon retirement, which appeared largely due to problems with his back. See February 2013 VA examination. Although in November 2008, he reported suicidal ideation, severe depression, lack of motivation, anxiety attacks, on a regular basis his mood was euthymic with an appropriate affect. After the November 2008 VA examination, the Veteran denied suicidal and homicidal ideation. Furthermore, consistently his speech was normal in rate, rhythm and volume. His cognition was intact. He denied auditory and visual hallucinations. There was no evidence of psychosis. His insight was generally good and his judgment was intact. His GAF scores ranged from 55, reflecting moderate symptoms, 65, reflecting mild symptomatology. After June 21, 2012, the evidence shows that the Veteran's symptoms markedly improved. He reported that his life was going pretty well. Leading up to June 2012, he reported sleeping longer than before (see March 2012 VA treatment records), and in November 2012 VA treatment, he admitted that he no longer had a problem going to sleep. He denied having nightmares and stated that he had not had a flashback in some time. VA examination reports described his symptoms as stable and his mood euthymic with little symptomatology. The February 2013 VA examiner assigned the Veteran a GAF score of 80, which reflects better than mild symptomatology. At that time, the Veteran denied many symptoms other than depressed mood and anxiety, with some difficulty falling or staying asleep and exaggerated startle response. Moreover, the Veteran stated that his overall symptom presentation was much less than it had been at an earlier time in his life. Additionally, the Veteran denied that his functioning was impaired. The Board finds that the Veteran's anxiety attacks were less frequent, his insomnia was improved, and his depressed mood was mild. As the disability picture associated with these symptoms more nearly approximates a 30 percent evaluation than a 50 percent or higher evaluation, an increased evaluation after June 21, 2012 is not warranted. In this case, total occupational and social impairment is not shown. The record indicates that the Veteran has a good relationship with his children and mother. In addition, the probative evidence does not suggest that any of the demonstrative symptoms of a 100 percent rating for PTSD are present or any other symptoms of the type and degree contemplated by a total rating are present. The Veteran has successfully communicated with examiners and abnormal behavior and disorientation have not been reported, there is no suggestion that he is persistently experiencing delusions or hallucinations, and while he had one report of suicidal ideation early in the appeal period, since that time, there has been no suicidal ideation. The Veteran has not alleged and the evidence does not suggest that he does not keep up with his activities of daily living or his personal hygiene, except for one report in February 2011. The Board contemplated such report in the now assigned 50 percent rating. Additionally, the Veteran does not have short-term memory loss to the degree of forgetting names of close relatives, his occupation, or his own name. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the AOJ refer a claim to the Under Secretary for Benefits or the Director, Compensation Service, for consideration of an extra-schedular evaluation. 38 C.F.R. § 3.321(b)(1) (2014). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this regard, the schedular evaluations in this case are not inadequate. Regarding the first step of Thun, the Board finds that the rating criteria reasonably describe the Veteran's disability and symptomatology. Of note, the symptoms listed in the General Rating Formula for Mental Disorders are merely demonstrative and not exhaustive. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The evidence does not reflect any symptom or degree of severity not contemplated by the General Rating Formula, which focuses on occupational and social impairment caused by all symptoms of a mental disorder. Therefore, the threshold factor for extra-schedular consideration under step one of Thun has not been met, and the Board need not reach the second step of the Thun analysis. As the disability picture is contemplated by the Rating Schedule, the assigned schedular ratings are, therefore, adequate. Finally, the Board notes that, under Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case there is simply no indication that any combination of the Veteran's service-connected disabilities rises to the level of an exceptional or unusual circumstance. Consequently, referral for extra-schedular consideration is not required under 38 C.F.R. § 3.321(b)(1). ORDER An evaluation of 50 percent, and no higher, for PTSD until June 21, 2012, is granted. An evaluation in excess of 30 percent for PTSD after June 21, 2012, is denied. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs