Citation Nr: 1539790 Decision Date: 09/16/15 Archive Date: 09/24/15 DOCKET NO. 09-08 282 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD), claimed as entitlement to an effective date earlier than May 21, 2013 for a 100 percent disability rating for PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran, his wife, his father, and his brother ATTORNEY FOR THE BOARD Harold A. Beach, Counsel INTRODUCTION The Veteran served on active duty from March 2004 to January 2008. He had service in Southwest Asia from November 2005 to November 2006. His awards and decorations included the Combat Action Badge. In July 2008, the RO granted the Veteran's claim of entitlement to service connection for PTSD. The RO assigned a 10 percent rating, effective January 28, 2008. The Veteran disagreed with that rating, and this appeal ensued. In June 2010, the RO revised its rating for PTSD to 30 percent; however, it retained the effective date of January 28, 2008. Because that rating was not a full grant of the benefits sought on appeal, the case was transferred to the Board of Veterans' Appeals (Board) for further appellate action. In March 2013, the Board remanded the case to the RO, in part, to obtain any outstanding records reflecting the Veteran's VA mental health treatment. The RO was to also schedule a VA psychiatric examination to determine the severity of the Veteran's PTSD. Following the requested development, the RO raised the Veteran's rating for PTSD to 100 percent. That rating became effective May 21, 2013, the date of the VA psychiatric examination. The Veteran disagreed with that effective date, and thus, he did not receive a full grant of the benefits sought on appeal. Accordingly, the case was returned to the Board for further appellate action. When returned to the Board the issue was characterized as entitlement to an effective date earlier than May 21, 2013, for a 100 percent disability rating for PTSD. The Board has recharacterized the issue on the title page to better reflect the scope of the appeal. In October 2012, the Veteran had a hearing at the RO before the Veterans Law Judge whose signature appears at the end of this decision. FINDING OF FACT From January 28, 2008 through May 20, 2013, the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW For the period from January 28, 2008 through May 20, 2013, the criteria for an initial rating of 50 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duty to Notify and Assist Prior to consideration of the merits of the Veteran's appeal, the Board must determine whether VA has met its statutory duty to assist him in the development of the issue of entitlement to an initial rating in excess of 30 percent for PTSD, claimed as entitlement to a 100 percent disability rating for PTSD, earlier than May 21, 2013. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. After reviewing the record, the Board finds that VA has met that duty. In December 2007, the VA received the Veteran's formal claim (VA Form 21-526) for service connection for PTSD. Following the receipt of that application, the VA notified the Veteran of the information and evidence necessary to substantiate and complete his claim, including the evidence to be provided by him, and notice of the evidence VA would attempt to obtain. VA informed him of the criteria for service connection, as well as the general criteria for rating service-connected disabilities and for assigning effective dates, should service connection be granted. Following the notice to the Veteran, VA fulfilled its duty to assist him in obtaining identified and available evidence necessary to substantiate his claim. The VA obtained or ensured the presence of the Veteran's service treatment and personnel records. The VA also examined the Veteran in February and May 2008. The VA examination reports show that the examiners reviewed the Veteran's medical history, documented his medical conditions, interviewed and examined the Veteran, and rendered diagnoses and opinions with respect to the nature and etiology of any psychiatric disorder and/or residuals of a traumatic brain injury found to be present. Therefore, the Board concludes that the VA examinations are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2009); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As noted above, the RO granted the Veteran's claim of entitlement to service connection for PTSD in July 2008 and assigned a 10 percent rating, effective January 28, 2008. The Veteran disagreed with that rating, and this appeal ensued. Inasmuch as it is derived from the initial service connection claim, the issue of entitlement to an increase rating is considered a "downstream" issue. Grantham v. Brown, 114 F.3d 1156 (1997). Although VA has not specifically notified the Veteran of the information and evidence necessary to substantiate the increased rating claim, such notice is not required in this case. In December 2003, the VA General Counsel issued a precedential opinion stating that, if VA received a notice of disagreement (NOD) in response to a decision on a claim for which VA had already sent the veteran a duty to assist letter, and the NOD raised a new issue, the duty to assist the appellant did not require VA to provide notice of the information and evidence necessary to substantiate the newly raised "downstream" issue. See VAOGCPREC 8-03, 69 Fed. Reg. 25180 (2004). The Board is bound by that opinion. 38 U.S.C.A. § 7104(c) (West 2002). Hence, the VA has essentially complied with its duty to assist the Veteran in the development of his claim of entitlement to an increased rating for PTSD. In developing the increased rating issue, the Board obtained or ensured the presence of records reflecting the Veteran's treatment from March 2008 to October 2010, statements from the Veteran's family, and the transcript of the October 2012 hearing before the undersigned Veterans Law Judge. The hearing transcript shows that the Veterans Law Judge explained the issues fully and suggested the submission of evidence that the claimant may have overlooked and that would be advantageous to his position. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). As such, the conduct of the hearing was performed in accordance with the provisions of 38 C.F.R. § 3.103(c)(2). Therefore, there was no prejudice to the Veteran's claim as a result of the conduct of that hearing. See Bryant, 23 Vet. App. at 498 (citing to 38 U.S.C. § 7261(b)(2); Shinseki v. Sanders, 129 S. Ct. 1696, 1704 (2009)). In sum, the Veteran has been afforded a meaningful opportunity to participate in the development of his appeal. He has not identified any outstanding evidence which could support his claim; and there is no evidence of any VA error in notifying or assisting the Veteran that could result in prejudice to him or that could otherwise affect the essential fairness of the adjudication. Accordingly, the Board will proceed to the merits of the appeal. Contentions During his hearing, the Veteran contended that he should have an effective prior to May 21, 2013 for his 100 percent schedular rating for PTSD. He stated that the rating prior to that time did not adequately reflect the severity of that disability. In essence, he was not only arguing for an earlier effective date, he was arguing for a rating in excess of his initial rating of 30 percent between the date that service connection became effective January 28, 2008 and the date that the 100 percent rating became effective. After reviewing the record, the Board agrees that the Veteran's PTSD was underrated from January 28, 2008 through May 20, 2013, and the appeal will be granted to the extent indicated. The Applicable Law and Regulations Disability evaluations are determined by comparing the manifestations of a particular disability with the criteria set forth in the Diagnostic Codes of VA's Schedule For Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity (in civilian occupations) resulting from service-connected disability. 38 C.F.R. § 4.1. Generally, the effective date of an award of service connection or of increased compensation for service-connected disability shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(o)(1). In this case, the appeal has been active since service connection became effective January 28, 2008, the day after the Veteran's separation from the service. 38 U.S.C.A. § 5110(a)- (b)(1); 38 C.F.R. § 3.400(b)(2)(i). Therefore, the Board will consider the possibility of an increased rating between the time that service connection became effective until the 100 percent rating became effective May 21, 2013. During an appeal, a veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim was filed until a final decision is made. When, as in this case, service connection is granted and an initial rating award is at issue, separate ratings can be assigned for separate periods from the time service connection became effective. Fenderson v. West, 12 Vet. App. 119 (1999) Therefore, the following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. PTSD is rated in accordance with the VA General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for PTSD when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for PTSD when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted for PTSD, when there are 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, own occupation, or own name. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Relevant to an evaluation of the severity of PTSD is the score on the Global Assessment of Functioning (GAF) Scale. That scale is found in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994) (DSM-IV) and reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996). The nomenclature in DSM IV has been specifically adopted by the VA in the evaluation of mental disorders. 38 C.F.R. § 4.125, 4.130 (2002). A GAF of 61 to 70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. DSM IV at 32. A GAF of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. Id.; see Carpenter v. Brown, 240, 242 (1995). A GAF of 41 to 50 signifies 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). Id.; see Richard v. Brown, 9 Vet. App. 266, 267 (1996)). While important in assessing the level of impairment caused by psychiatric illness, the GAF is not dispositive of the level of impairment cause by such illness. Rather, it is considered in light of all of the evidence of record. See Brambley v. Principi, 17 Vet. App. 20, 26 (2003); Bowling v. Principi, 15 Vet. App. 1, 14 (2001). Effective March 19, 2015, the VA revised that portion of its Schedule for Rating Disabilities dealing with mental disorders. The revisions replaced outdated references in earlier editions of DSM with revisions in the recently updated Fifth Edition (DSM-5). Such revisions apply to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction (AOJ) on or after August 4, 2014. The Secretary of the VA does not intend for the revisions to apply to claims that were pending before the Board (i.e., certified for appeal to the Board on or before August 4, 2014), the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims are subsequently remanded to the agency of original jurisdiction. Because this case was certified to the Board prior to August 4, 2014, the revised regulations do not apply. The Evidence During his last year of service, the Veteran was treated for PTSD and was ultimately given a medical discharge due, in part, to that disorder. In August 2007, he underwent a psychological consultation in conjunction with his medical board proceedings in service. The examiner diagnosed chronic, severe, PTSD, manifested primarily by avoidance behavior and severe anxiety attacks resulting in vomiting, hyperarousal, insomnia, nightmares, and intrusive memories. The examiner opined that there was marked impairment for further military duty, as well as considerable impairment of social/industrial adaptability. The examiner also diagnosed moderate depressive disorder, not otherwise specified. It was manifested, primarily, by a depressed. mood, crying spells, irritability, anhedonia, social withdrawal, and a feeling of being cut off from others. Again, the examiner opined that there was marked impairment for further military duty. She also found definite impairment for social/industrial adaptability. The examiner noted that the Veteran had received some positive response from psychotherapy, psychotropic medication, and medication for insomnia. She opined that continuation on active duty was likely to make further progress difficult but that ultimate prognosis was favorable with both medication and psychotherapy for an indeterminate period of time. At the time of his August 2007 evaluation, the examiner stated that the Veteran was not an, imminent, danger to himself or others. She assigned a GAF of 50. In February 2008, shortly after his discharge from the service, the Veteran was examined by the VA to determine the nature, etiology, and extent of any psychiatric disorder found to be present. He reported sleep disturbance, irritability, and brief depressive periods. He also reported persistent, recollection of his stressor event approximately twice a week; frequent, persistent distressing dreams of the event; avoidance of cues that would remind him of the event, a markedly diminished interest or participation in significant activities; and a feeling of detachment or estrangement from others. It was noted that the Veteran continued to take psychotropic medication and that during the previous year, he had received psychiatric treatment approximately twice a month. He described the treatment as pretty helpful and noted that he had not gone to the emergency room or received any hospitalization for his psychiatric disabilities. . On examination, the Veteran was friendly and cooperative with good eye contact. He was casually dressed, and his appearance and hygiene were appropriate. His affect and mood were normal, and there was no evidence of anxiety or suspiciousness. His orientation was within normal limits, as were his communication and speech. His concentration and memory were also within normal limits. The Veteran did not present a history of delusions or hallucinations and none were observed during the examination. His behavior was appropriate and obsessional rituals were absent. His thought processes were also appropriate, and his judgment and abstract thinking were not impaired. Suicidal and homicidal ideations were absent. Following the examination, the diagnosis was PTSD, mild, and the examiner assigned a GAF of 65 to 70. The examiner noted that mentally, the Veteran had some occasional interference in performing activities of daily living because of PTSD symptoms. The examiner described the Veteran's psychiatric symptoms as mild or transient. The examiner opined that they caused occupational and social impairment with a decrease in work efficiency and occupational tasks only during periods of significant stress. The Veteran was found to have no difficulty understanding commands and appeared to pose no threat of persistent danger or injury to himself or others. In May 2008, the Veteran was examined by the VA for claimed residuals of a traumatic brain injury. He reported many of the symptoms he had reported during his February 2008 psychiatric examination: fatigue; a lack of desire to do anything; memory problems; problems with attention/concentration; anxiety over inability to get a job; depression for which he continued to take medication; crying spurts; irritability; and trouble sleeping. On examination, the Veteran was alert and oriented to person, place and time, and his attention was normal, as indicated by his ability to answer difficult questions and stay focused. His memory was also normal, as evidenced by his ability to remember names, tasks and his occupation. The diagnoses included PTSD. The examiner noted that the Veteran was having trouble finding work; that he was sleep deprived, and that he had no energy to pursue life. From March 2008 through October 2010, the Veteran was treated by the VA for PTSD. During his initial evaluation by the Mental Health Service in March 2008, he complained of depression, nightmares which interfered with his sleep, little interest in anything, a poor appetite and low energy. He stated that he did not go out much and that he felt isolated. He reported a history of panic attacks but none since August 2007. He noted that he was in the process of starting an electrical business with his brother and that he had a goal of getting his Bachelor's degree in Accounting. On examination, the Veteran demonstrated an average mood and affect. It was noted that he usually processed his thoughts well but that at times, he was overwhelmed. He reported average intelligence and problems with his short term memory. He stated that he had never had any suicidal or homicidal ideations. The diagnoses were PTSD and depressive disorder, not otherwise specified. The examiner assigned a GAF of 65. In February 2009, the Veteran began working with the VA Speech Therapy Service to assist him with his pursuit of a college education. The primary focus was on improving his memory and organizational and study skills. In September 2009, it was noted that the Veteran had made progress, initially, but then had experienced lots of ups and downs with comorbid physical problems and a recent suicide of a very close friend and fellow soldier. In March 2009, it was noted that the Veteran had experienced a downward trend since the January 2006 anniversary date of his stressful experience in Iraq. He reported that he was depressed and had poor sleep with nightmares. He also reported additional symptoms of re-experiencing the event, avoidance behavior, hyperarousal, irritability, and panic attacks. In May 2010, the Veteran was discharged from Speech Therapy. It was noted that he would complete his associate's degree by fall of 2011 and that he wanted to go on for his bachelors degree.as well. He also received a job offer to run a company's information technology department. In addition, he got full custody of his children from his first marriage and stated that he felt better overall. In sum, the VA Speech Therapy Service noted that the Veteran had progressed initially w/ therapy but had a significant setback which was very stressful and emotional and cause his therapy to be extended. He had reportedly shown significant improvement in all areas especially in the previous 4 months. He had a 4.0 average with classes under his belt and had started his own website for Veterans. He was feeling better emotionally, and he appeared to have more confidence in himself. His note taking and test taking had both improved, and he was better able to attend in class shutting out the distractions During VA treatment in August 2009, it was noted that the Veteran and his wife took in a 16 year old German Foreign Exchange student. The student was involved in football and other school activities, and it was noted that the Veteran had been very busy with that, and enjoying it, as well. From November 2009 through February 2010, the Veteran received monthly VA psychotherapy. His PTSD was manifested primarily by nightmares, a depressed mood, an impaired memory, and periods of loneliness. Generally, he was alert, oriented and cooperative. His psychomotor processes were within normal limits. His speech was clear, and his thoughts were goal directed. There was no evidence of delusions or hallucinations and he denied suicidal or homicidal ideations. His assigned GAF's ranged from 55 to 65. In November 2009, it was noted that the Veteran had improved but that he still experienced the following symptoms "quite a bit": repeated disturbing memories, thoughts, or images of the stressful event; repeated disturbing dreams of the stressful event; flashbacks; upset and physical reaction to reminders of the stressful event; avoidance behavior; loss of interest in formerly enjoyable activities; distance from others; emotional numbness, a foreshortened future, irritability, difficulty concentrating; hypervigilance; and startle reaction. In January 2010, the Veteran was in good spirits. His wife had thrown him a wonderful 30th birthday party, and he had had a great time with best friend and the Veteran's very large family. In January, it was the anniversary of his stressful event, and he continued to experience periods of loneliness On examination, his mood was depressed. In March 2010, the Veteran was reexamined by the VA to determine the severity of his PTSD. He continued to report nightmares, intrusive thoughts, panic attacks, and isolation, as well as depression, trouble sleeping, irritability, minimal pleasure, low energy, and a lack of motivation. In addition, his continued to report recurrent recollections of his stressful event, avoidance behavior, startle response, and hypervigilance. He also reported flashbacks, survivor guilt, and paranoia. He denied a history of violence and did not indicate a history of suicidal attempts. The severity of his symptoms was noted to be moderate. The Veteran indicated that his symptoms affected his total daily functioning. On examination, the Veteran demonstrated a mild to mod depressed mood and suspicion. He reported homicidal and suicidal ideation but no intent. It was noted that he had panic attacks 2 to 3 times a week and compulsive behavior which interfered with his routine activities. He stated that he checked the locks on windows and doors 3 times before going to bed. During the examination, it was noted that the Veteran's familial relationships with his parents and siblings were good. His marital relationship was reportedly strained due to the Veteran being withdrawn. It was also noted that for the previous 18 months, he had been working part time. His relationship with his supervisor was reportedly good, and his relationship with his co-workers was also good. It was noted that he had not lost any time from work. Following the examination, the diagnoses included PTSD and depression. The examiner assigned a separate GAF of 60 for each of those disorders. The examiner noted that since service, the Veteran's quality of life had declined due to PTSD. The examiner also noted that due to PTSD and depression, the Veteran experienced some occasional has some interference in performing activities of daily living. The VA examiner opined that the Veteran's psychiatric symptoms caused occupational and social impairment with reduced reliability and productivity. The examiner based that statement on the fact that the Veteran experienced panic attacks more than once a week; that he had difficulty in understanding complex commands; that he displayed impairment in short and long term memory (e.g. retention of only highly learned material, forgetting to complete tasks); that he had disturbances of motivation and mood; that he had difficulty in establishing and maintaining effective work and social relationships; and that he had difficulty understanding complex commands. Based upon the examination, the examiner concluded that the Veteran required ongoing mental health therapy. The examiner further opined that the Veteran did not appear to pose any threat of danger or injury to himself or others. The prognosis for the Veteran's psychiatric condition was fair. During VA treatment in May 2010, the Veteran reported that with respect to his mood, he was having mostly good days. His primary manifestations of PTSD were numbness and distant feeling, avoidance behavior, hypervigilance, and an exaggerated startle response. He reported that his irritability was a little better and that his recurrent/intrusive thoughts were not too bad but still occurred. He stated that his anxiety was better overall and that he slept okay without medication. He also reported that his nightmares were better on medication and that he had not had any panic attacks sine increasing his medication dosage. His energy reportedly varied from day to day, and his concentration was usually okay. He tried to be sociable and continued to do things by himself that he enjoyed. He denied audio/visual hallucinations, delusions, or paranoia and had no homicidal or suicidal thoughts. He stated that his hopelessness was subsiding and that his family helped with that. In June 2010, the Veteran's brother stated that he saw the Veteran was forgetful, paranoid/hypervigilant, easily startled and, at times, tearful due to disturbing dreams. He stated that he saw the Veteran at family functions and when their boys played together. He noted that the Veteran participated monthly in a Worship Band at church and that he could not remember rehearsal times without being reminded and struggled to remember how to play songs they had been playing for years. During VA treatment in August 2010, the Veteran's primary manifestations of PTSD continued to be numbness and distant feelings, avoidance behavior, hypervigilance, and an exaggerated startle response. He reported feeling down most days and that his irritability was high. He also reported that his anxiety level was high because he and his wife were buying a new house. He stated that he felt hopeless about not doing the things that he wanted to do. Following that treatment, the examiner assigned a GAF of 52. In an October 2012 letter, the Veteran's wife reported that the Veteran had multiple disorders involving his head: PTSD, a traumatic brain injury, major depressing, ringing in his ears, deafness, daily migraines, extraction of the majority of his back teeth due to them being shattered, issues with his vision due to exposure to the sun, and vertigo/lack of balance. She stated that he had daily ongoing nightmares, irritability, withdrawing behaviors, short and long term memory loss, and difficulty to thinking neutrally/positively. She noted that the Veteran had been let go from three jobs due to inability to produce up to their standard. She also noted that he had remained unemployed and had engaged in affairs with 6 women in the last 4 years. She stated that he often forgot plans that had been made, promises that he has made to his sons, celebrations that had been planned, and regularly scheduled events. She reported that the Veteran was man of good intention and hopeful character and that he tried to do his best for his family. She stated that he worked to smile for them and that he went to the boys' sports events. She also reported that he tried to listen to her after a long day of her work. During his October 2012 hearing, the Veteran reported that his PTSD had gotten worse since his February 2010 VA examination. He testified that at times, his PTSD was debilitating and that he could not get out of bed. He also testified that he had suicidal ideation approximately every 6 months. He stated that he was always worried, always anxious, that he his sleep was interrupted, that he had nightmares 3 to 4 times a week, and that he had panic attacks 5 times a week. He reported that he had had a few part-time jobs since service but had lost them due to panic attacks, lots of doctor appointments, and lack of work. He testified that he was socially inhibited, that he rarely went to movies, and that he struggled to go to his children's sporting events. He also testified that because he was limited by PTSD, it placed a greater burden on his spouse, which caused animosity. Analysis When determining the appropriate rating to be assigned for the Veteran's service-connected PTSD, the Board will identify the symptoms associated with that disability and focus on how the frequency, severity, and duration of those symptoms affect his occupational and social impairment. The symptoms listed in the General Rating Formula for Mental Disorders are examples, not an exhaustive list and any suggestion that the Board is required to find the presence of all, most, or even some of the enumerated symptoms is unsupported by a reading of the plain language of the regulation. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). A review of the evidence dated through May 20, 2013, discloses that the Veteran's PTSD is manifested, primarily by a depressed mood, impaired sleep with nightmares, memory and concentration problems, irritability, hypervigilance, startle reaction, and a history of panic attacks more than once a week. He has good days such as in May 2010, when he had educational successes and a job offer to run a firm's information technology department. He also has bad days as in early 2009 when a friend and former fellow soldier committed suicide. While the evidence shows progress in the effects of his PTSD and his GAF scores have, generally, been above 50, his primary manifestations more nearly reflect the schedular criteria associated with a 50 percent rating. In particular, the VA General Rating Formula for mental disorders lists panic attacks more than once a week, disturbances of motivation and mood, and impaired memory, among the types of symptoms associated with a 50 percent rating. 38 C.F.R. § 4.130. In this regard, it must be emphasized that the GAF score is not dispositive of the level of impairment cause by such illness. Rather, it is considered in light of all of the evidence of record. When combined with impaired sleep with nightmares, irritability, hypervigilance, and startle reaction, the Board finds that the manifestations of the Veteran's PTSD support the 50 percent rating. At the very least, there is an approximate balance of evidence both for and against the claim that an increased rating is warranted for the period from January 28, 2010 through May 20, 2013. Under such circumstances, all reasonable doubt is resolved in favor of the Veteran, and the appeal will be decided on that basis. 38 U.S.C.A. § 5107(b) ; 38 C.F.R. § 4.3. Accordingly, a 50 percent rating is warranted for the period indicated. To that extent, the appeal is allowed. In arriving at this decision, the Board has considered the possibility of a still-higher schedular rating. Although the 70 percent rating criteria contemplate deficiencies in most areas, including work, school, family relations, judgment, thinking, or mood, such deficiencies must be due to the symptoms listed for that rating level, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Simply because this Veteran has depressed mood, and because the 70 percent level contemplates a deficiency in "mood" among other areas, does not mean his PTSD rises to the 70 percent level. Indeed, the 30 percent, 50 percent, and 70 percent criteria each contemplate some form of mood impairment. The Board, instead, must look to the frequency, severity, and duration of the impairment. Id. Here, the Veteran's depressed mood is reflected by the 50 percent criteria, which contemplates "disturbances" in mood. 38 C.F.R. § 4.130. The Veteran is adequately compensated for that impairment. The same holds true for the Veteran's memory problems and panic attacks more than once a week. While he testified that he has at least 5 attacks a week, suggesting near continuous panic, the preponderance of the evidence is against such a finding. Neither the treatment records, nor the examination reports, nor the lay statements show such frequency. The Board also finds that the Veteran's PTSD symptoms cause occupational and social impairment to at least some degree. Given the frequency, nature, and duration of those symptoms, the Board finds that they result in no more than occupational and social impairment with reduced reliability and productivity. Due to reported deficits in memory, note taking, and test taking, the Veteran received assistance from the VA Speech Therapy Service. He persevered through much of the period to complete his education with excellent grades, often working part time. In addition, the evidence shows that the Veteran is close to his family. During the period from January 28, 2008 through March 20, 2010, he reportedly attended his children's' athletic events and was present when his children played with their cousins. He regularly attended church and played in a church music group. Further, he enjoyed a 30 birthday party and opened his house to a foreign exchange student. Indeed, neither the health care providers nor the examiners have found, occupational and social impairment with deficiencies in most areas, such as work, school, family relations, and mood due to judgment, thinking or mood. Such findings do not more closely approximate the frequency, severity, and duration of the types of symptoms contemplated by a 70 percent rating. Therefore, a 70 percent rating is not warranted. See Vazquez-Claudio, 713 F.3d at 114 (holding 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"). Inasmuch as the Veteran does not meet or more nearly approximate the criteria for a 70 percent rating, the Board need not discuss the criteria for a 100 percent rating prior to May 21, 2013. In arriving at this decision, the Board has considered the possibility of referring this case to the Director of the VA Compensation and Pension Service for possible approval of an extraschedular rating for the Veteran's service-connected PTSD. 38 C.F.R. § 3.321(b)(1) (2014). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but would still be adequate to address the average impairment in earning capacity caused by the disability. Thun v. Peake, 22 Vet. App. 111, 114 (2008). However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). There is a three-step inquiry for determining whether a claimant is entitled to an extraschedular rating. Thun, 22 Vet. App. at 115. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Board must compare 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. Id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular evaluation is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors, such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a claimant's disability picture with such related factors as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. The Board finds that neither the first nor second Thun element is satisfied here. The Veteran's service-connected PTSD is manifested, primarily, by signs and symptoms of a depressed mood, impaired sleep with nightmares, memory and concentration problems, irritability, hypervigilance, startle reaction, and a history of panic attacks more than once a week. Such manifestations are contemplated by the schedular criteria in 38 C.F.R. § 4.130, Diagnostic Code 9411 and the manifestations incorporated in DSM IV. There is nothing exceptional or unusual about the Veteran's PTSD, because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. Therefore, he does not meet the criteria for referral to the Director of the VA Compensation and Pension Service. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the Veteran does not contend, and the evidence of record does not suggest, that his service-connected PTSD has resulted in any hospitalizations or that PTSD, alone, caused marked impairment with employment. Although the Veteran's wife reports that he has lost 3 jobs due to an inability to produce up to company standards, that is not borne out by the evidence, including the history in the reports of the Veteran's treatment or examinations. Moreover, she suggests multiple service-connected and nonservice-connected disabilities responsible for those job losses, rather than job losses solely to PTSD. In addition, the Veteran has testified that his job losses were due to a variety of reasons, including lack of work, not solely PTSD. The Board finds, therefore, that the Veteran's service-connected PTSD does not result in marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Thus, even if his disability picture was exceptional or unusual, referral would not be warranted. ORDER For the period from January 28, 2008 through May 20, 2013, entitlement to an initial 50 percent rating for PTSD is granted, subject to the law and regulations governing the award of monetary benefits. ____________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs