Citation Nr: 1630930 Decision Date: 08/03/16 Archive Date: 08/11/16 DOCKET NO. 11-29 973 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) (previously evaluated as an anxiety disorder). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Osegueda, Counsel INTRODUCTION The Veteran served on active duty in the United States Marine Corps from August 1965 to August 1968, and in the Air National Guard from August 1983 to June 1984 and from September 1984 to December 1996. His awards and decorations include the Purple Heart Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In that rating decision, the RO granted service connection for an anxiety disorder, and assigned a 30 percent evaluation, effective September 29, 2009. The Veteran appealed the assigned rating. In a November 2014 decision, the Board denied an initial evaluation in excess of 30 percent. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2016 memorandum decision, the Court vacated the portion of the Board's decision that denied an initial evaluation in excess of 30 percent for PTSD and remanded the matter for further proceedings consistent with its decision. This appeal was processed using the Veterans Benefits Management System (VBMS) and the Virtual VA paperless claims processing systems. Any future consideration of this Veteran's case must take into account the existence of these electronic records. FINDING OF FACT The Veteran's PTSD has been manifested by symptoms causing occupational and social impairment with reduced reliability and productivity. He does not have occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for an initial evaluation of 50 percent, but no higher, for PTSD have been approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the Veteran is challenging the initial evaluation assigned following the grant of service connection for his PTSD. In Dingess, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8- 2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records and all identified, relevant, and available post-service medical records have been associated with the claims file and were reviewed by both the RO and the Board in connection with the claim. The Veteran has not identified any other outstanding records that are pertinent to this case. In addition, the duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was afforded VA examinations in February 2010, October 2011, May 2013, and March 2014. As discussed below, the Board finds that the VA examinations in this case are adequate, as they are predicated on a review of the Veteran's medical history as well as on an examination, and they fully address the rating criteria that are relevant to rating the Veteran's PTSD. Moreover, the evidence of record does not indicate that there has been a material change in the severity of the Veteran's PTSD since he was last examined in March 2014. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Thus, the Board finds that there is adequate medical evidence of record to make a determination in this case. Accordingly VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2015). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Law and Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While 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, as here, the question for consideration is a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is currently assigned a 30 percent disability evaluation, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under Diagnostic Code 9411, a 30 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in 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 work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the psychiatric disorder results in 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. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013), the U.S. Court of Appeals for the Federal Circuit stated 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." "Although the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of [occupational and social] impairment." Id. The Board notes that the regulations were recently revised to incorporate the Fifth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V) rather than the Fourth Edition (DSM-IV). However, these provisions only apply to cases received by or pending before the AOJ on or after August 4, 2014. The change does not apply to cases certified to the Board prior to that date. In this case, the Veteran's claim was certified to the Board prior to August 4, 2014; therefore, the regulations pertaining to the DSM-IV are for application. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the DSM-IV, GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Historically, in September 2009, the Veteran applied for service connection for an anxiety disorder. In a November 2009 statement, the Veteran reported difficulty sleeping and problems controlling his anger. During a February 2010 VA PTSD examination, the Veteran reported that he had periods of anger that lasted from one day to one week and difficulty sleeping. He noted that he generally had an "equal number of good days compared to bad days lately." He stated that his future and quality of life were "good." He stated that he began working at the post office in 1969 and retired from his position as a letter carrier in 2004 when he was 57 years old. He reported that he drove an auto parts truck to "keep busy" for the past five years. He indicated that he worked 40 hours per week as a full-time driver. He indicated that he had been married for 41 years, and he had two adult daughters and six grandchildren. He denied any history of psychiatric hospitalization, treatment, or counseling. He also stated that he did not think that he needed any mental health treatment based on the severity of his symptoms. On examination, the Veteran was dressed casually with good grooming and hygiene. He was alert and oriented to person, place, and time. No fine or gross motor impairments were observed. His thought processes were generally clear and goal-directed. His speech was soft, generally articulate and clear, and within normal limits for volume, rate, rhythm, and prosody. His immediate memory appeared intact. The examiner noted that the Veteran made minor errors on short-term and delayed memory tasks, which suggested mild impairment in short-term memory on screening. However, tests of mental control were generally unimpaired. The Veteran's attention appeared intact, concentration was mildly impaired, and impulse control appeared within normal limits. His verbal abstract reasoning skills were generally abstract. The Veteran reported that his mood was irritable, occasionally down, and tense at times. His affect was broad and appropriate to content. He reported mild problems with worry, and noted that his stress levels were often affected by life events, such as difficulty in his relationship with his wife due to her symptoms of bipolar disorder. The examiner noted that the Veteran reported anhedonia, but then stated that he enjoyed hunting, fishing, and spending time with his grandchildren. He reported difficulty staying asleep (woke one to two times per night), occasional nightmares (once per month), and feeling tired. No psychomotor agitation or retardation was noted. He reported mild problems with concentration. He denied suicidal or homicidal ideation; visual or auditory hallucinations; and paranoid thinking or delusions. His insight and judgment appeared grossly intact. During the February 2010 VA examination, the Veteran stated that he had a good relationship with his supervisor and co-workers. He denied ever missing work due to psychological or emotional problems. He indicated that he spent time at home with his wife after work, and he worked on projects around the house or watched television. He stated that he was bothered by crowds and that he preferred to spend time with his immediate family or alone. He related that he felt emotionally close to his family members. He reported that he did not consider himself an easy person to get along with because he tended to become quiet when he felt nervous. He indicated that he had a good relationship with his wife, but they went though some "rough patches" because his wife had undiagnosed bipolar disorder for many years. He stated that their relationship is better now that she received psychiatric care. He also indicated that he had a good relationship with his daughters and a great relationship with his grandchildren. The examiner concluded that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD. He noted that the Veteran endorsed some PTSD-spectrum symptoms that were more consistent with a diagnosis of an anxiety disorder. A GAF score of 68 was assigned. The examiner opined that the Veteran's anxiety symptoms were not severe enough to interfere with his occupational functioning, but his symptoms did appear to result in mild impairment in his social relationships. During a July 2010 VA psychology consultation, the Veteran stated that he had anger on a daily basis, anxiety in crowds, and difficulty sleeping. He noted that he had three nightmares in the past month. He stated that he avoided other veterans, anything related to the military, crowds, and baseball stadiums. He also noted that when he was in a crowd, he became "worked up." He stated that he was unable to relax because he watched everything and waited for something to happen. He reported that he did not like going out, he isolated himself, and he felt better alone. He indicated that he did not want to be around other people. He indicated that he slept for six hours per night, but it was disturbed sleep with a lot of dreams. He endorsed difficulty with concentration, an inability to focus, and hypervigilance. He stated that his anger made him feel depressed. He denied mania, panic, and auditory or visual hallucinations. He related that he had loving feelings towards his family, but he lost all compassion for others. He indicated that he had been married to his wife for 41 years and described their relationship as "rough, with its ups and downs, but I love my wife." He stated that they leaned on each other. He noted that he had two adult daughters and six grandchildren. He stated that he had a close relationship with his parents, but he was not close with his younger brothers whom he saw once per year. He related that he liked spending time with his family because they were in his "comfort zone." He reported that he had no friends of his own, but he did socialize with his wife's friends on occasion. He described himself as "more of a loner." He indicated that he enjoyed hunting and fishing by himself. He stated that he worked full-time as a driver since 2004. He related that he would prefer to retire, but he needed the income and health insurance. Before his current job, he delivered mail for 35 years for the post office and retired in 2004. He explained that he liked the job because he did not have to talk to others. He stated that he would not have been able to perform other jobs with more social interaction. A mental status examination revealed an affect congruent with the Veteran's reported angry, nervous mood. He was fully oriented; casual and tidy in appearance; and cooperative. His thought processes and content were coherent, logical, and goal-directed. He denied any memory issues and suicidal or homicidal thoughts or potential. The diagnosis was an anxiety disorder and a GAF score of 68 was assigned. In an October 2011 addendum, it was noted that the GAF score was related to a mild level of impairment to social functioning. In a September 2010 VA psychology note, the psychologist noted that the Veteran was previously evaluated for PTSD in July 2010; however, it was unclear if his symptoms were consistent with PTSD. During the assessment, the Veteran reported that he wanted treatment for anger issues, anxiety in crowds, and difficulty sleeping. He stated, "I can't tell you the last night I had a full night of sleep; I wake frequently." He explained that his problems began after he returned from Vietnam. He reported, "I felt alienated upon [my] return from [Vietnam.] [P]eople were blaming us. I was bitter and angry; I still have these issues. I still feel anger that the country let us down. I lost all compassion for people." In a February 2011 VA psychology note, the Veteran indicated that he was looking forward to retirement in July. He mentioned that he was applying the coping skills that he was learning in PTSD classes. He noted that he was sleeping better, but he still woke throughout the night. He stated that his wife had a lot of her own problems and that he held a lot of his anger in. He denied any suicidal ideation. A mental status examination showed the Veteran's mood and affect were normal, and he was alert and oriented to person, place, and time. He denied any delusions or hallucinations and suicidal or aggressive behaviors. During an October 2011 VA PTSD examination, the Veteran reported that his marital relationship had not changed. He endorsed minimal involvement in social activities outside of time spent with his family. He remained employed as a driver for an auto parts company. He stated that his job was primarily isolative in nature, which worked well for him. He reported that he participated in group PTSD counseling and that he was interested in attending sleep management and anger management groups within the PTSD clinic. He stated that he continued to have disturbed sleep with nighttime waking and delayed return to sleep. He noted that he was uncomfortable in social situations, but he did attend some social events, such as family weddings. He indicated that he did not attend large sporting events, such as baseball games. He reported that he felt better alone and participated in hobbies, like hunting and fishing, alone. He endorsed continued anger and irritability. He stated that he felt "empty inside" and that he did not have a lot of compassion. Symptoms such as suicidal ideation, panic attacks, flattened affect, impaired memory, impaired judgment or disturbances of mood were not found. The October 2011 VA examiner concluded that the Veteran met the diagnostic criteria for PTSD and assigned a GAF score of 65. The examiner opined that the Veteran's PTSD appeared to have not impacted his occupational functioning and, to a mild degree, impacted his social functioning. Specifically, the examiner noted that the Veteran reported mild discomfort in social settings and a preference for isolative activities. The examiner further stated, "Any impairment is mild. Veteran has been able to maintain a 35 year career in the postal service and a second career as a delivery driver. He maintains that working in an isolative environment has been appropriate for him. He has been able to maintain appropriate social relationships with his family members." In addition, the examiner noted that the Veteran's report of severity of symptoms and impact to his social and occupational functioning did not appear to have changed since his February 2010 VA examination. The examiner stated, "Regardless of the diagnosis of either [an] anxiety disorder []or PTSD, the impact to social and occupational functioning appears mild given his ability to maintain a successful career to retirement and a second career as well as a satisfactory marriage." During a May 2013 VA traumatic brain injury (TBI) examination, the examiner noted that the Veteran did not have, nor did he ever have, a TBI. The Veteran described mild memory loss. The examiner noted that the Veteran's judgment was normal and his social interaction was routinely appropriate. He also indicated that the Veteran was always oriented to person, place, time, and situation, and his visual spatial orientation was normal. The examiner concluded that the Veteran did not suffer from TBI, but, rather, he had significant issues with PTSD. During a May 2013 VA psychiatric examination, the examiner noted that the Veteran presented with significant hostility, including expressing anger and irritation about his treatment as a returning veteran. The Veteran indicated that his relationship with his daughters had improved since he became involved with the PTSD clinic. Otherwise, the examiner noted that there was no significant change regarding the Veteran's social and family relations. The Veteran reported that his activities had been limited to work, assisting in his wife's care, and household chores. He stated that he and his wife visited their lake home every other weekend, and that he enjoyed taking his boat out on the lake to fish. He also indicated that he was involved in yardwork and gardening on his days off. He reported no change in his occupational status or functioning. He remained a full-time driver for an auto parts supplier. He stated that he planned to retire later in the year. He reported that he had continued ongoing sleep disturbance. He described waking during the night and checking to make sure that his doors and windows were secure. Examination revealed chronic sleep impairment resulting from PTSD. The Veteran endorsed isolative behavior and he noted that he did not go out in crowds. He indicated that he continued to hunt and fish alone. He stated, "I feel better by myself." He stated that he did not trust anyone and that he did not let anyone get close to him. He endorsed a restricted range of affect. He also reported, "I quit dealing with people... I would get so angry I would have killed somebody if I could have got[ten] away with it." He explained that he bottled up his anger which resulted in three trips to the hospital for stomach-related complaints. The examiner noted that the Veteran had not been involved in counseling services since his last VA examination in October 2011 although he was referred for anger management classes. The Veteran indicated that he planned to engage in more treatment services after his planned retirement later in the year. The Veteran denied suicidal ideation, and there were no findings of depressed mood, anxiety, panic attacks, or memory impairment. He was fully oriented in all spheres with no disturbance of motivation and mood. There were no other symptoms attributable to mental disorders. The May 2013 VA examiner opined that the Veteran's PTSD symptoms resulted in "[o]ccupational and social impairment due to mild or transient symptoms[,] which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress." The examiner also stated that the Veteran's PTSD symptoms did not appear to impact his occupational functioning given his ability to remain employed in a relatively isolative environment. The examiner provided, "Any impairment is mild. Veteran has been able to maintain a 35-year career in the postal service and a second career as a delivery driver. He maintains that working in an isolative environment has been appropriate for him. He has been able to maintain appropriate, although somewhat distant, social relationships with his family members." The examiner further noted that there had been no change since the October 2011 VA examination. During a March 2014 VA PTSD examination, the Veteran denied any changes to his family or social relationships. The Veteran had retired since the May 2013 VA examination. He indicated that he spent most of his time at home working on various projects and fishing at the lake when the weather allowed. He denied any significant changes in his activities or hobbies. He continued to enjoy hunting and fishing by himself. He also enjoyed taking walks when the weather allowed. He described continued sleep disturbances. He stated, "when I wake up like that, I have to get up . . . I have to check the perimeter . . . I know it is locked . . . if I lay there I can't get back to sleep knowing that I haven't checked it." The examiner noted that the Veteran was appropriately dressed and responded appropriately throughout the examination. There were no obvious difficulties with speech, concentration, gait, orientation, or fund of knowledge. The examiner provided the following: Veteran does not, today, describe any different symptoms related to his diagnosis of PTSD in comparison to his May 2013 examination. He identifies primarily isolative behavior, avoidance of reminders/crowds/social settings, detachment from others, hypervigilance, sleep disturbance[,] and irritability. He also identifies anger that he "missed out" on things, and anger about how the [Vietnam] veterans were treated[.] "I have never been able to get over that[,]" which he attributes to his anxiety symptoms. Veteran's diagnosis of PTSD is continued. He does not describe any different, or worsening of symptoms, in comparison to his May 2013 examination. The examiner opined that the Veteran's PTSD caused occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a higher initial rating of 50 percent for PTSD. However, the Board also finds that the Veteran is not entitled to an initial evaluation in excess of 50 percent for the entire period on appeal. The Board finds that the disability picture, to include the severity, frequency, and duration of his symptoms, as well as the resulting impairment of social and occupational functioning, is more consistent with a 50 percent rating throughout the period on appeal. A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Throughout the entire period on appeal, the Veteran has maintained a history of symptoms that predominantly include nightmares, sleep impairment, irritability, anger, avoidance of crowds, mild memory loss, problems with concentration, an inability to focus, hypervigilance, and discomfort in social settings. The Board finds that these symptoms and the social and occupational effects related thereto support a 50 percent evaluation for the period on appeal. See Vazquez-Claudio, 713 F.3d at 118. Nevertheless, the Board finds that the record does not demonstrate that the Veteran's overall disability picture is consistent with a 70 percent rating or higher during the appeal period. To the extent these symptoms may be shown or argued, the Board emphasizes that the Veteran's PTSD has not been shown to be productive of more than occupational and social impairment with reduced reliability and productivity. A 70 percent rating is warranted when the psychiatric disorder results in 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 work-like setting); inability to establish and maintain effective relationships. In this case, the record does not demonstrate that the Veteran's overall disability picture is consistent with a 70 percent rating or higher during the appeal period, to include consideration of the Veteran's lay statements, VA treatment records, and the VA examinations. As to occupational impairment, the Veteran maintained steady full-time employment until he retired sometime between the May 2013 and March 2014 VA examinations. He was employed as a driver for an auto parts supplier. Throughout the appeal, the Veteran repeatedly indicated that he worked 40 hours per week as a driver, and he had previously worked as a letter carrier for the postal service from 1969 until 2004. See February 2010 VA examination report, July 2010 VA psychology consultation report, October 2011 VA examination report, May 2013 VA examination report. During a February 2010 VA psychology consultation, the Veteran indicated that he liked his driving job because he did not have to talk with other people, and he was unsure if he would have been able to perform other jobs with more social interaction. In addition, during the October 2011 VA examination, he maintained that working in an isolative environment was appropriate for him. However, during the February 2010 VA examination, he stated that he had a good relationship with his supervisor and co-workers. Notably, the Veteran also denied ever missing work due to psychological or emotional problems. As to social impairment, throughout the period on appeal, the Board notes that the Veteran maintained a marriage to his wife for over 40 years. See February 2010 VA examination report, July 2010 VA psychology consultation report. The Veteran indicated that his stress levels were often affected by life events, such as difficulty in his relationship with his wife due to her symptoms of bipolar disorder. See February 2010 VA examination report. During a February 2010 VA examination, the Veteran indicated that he had a good relationship with his wife with some "rough patches" due to his wife's undiagnosed bipolar disorder for many years. However, he related that their relationship had improved since his wife began receiving psychiatric treatment. In addition, throughout the appeal, the Veteran indicated that he had a "good relationship" with his two adult daughters and a "great relationship" six grandchildren. See February 2010 VA examination report. In addition, during the May 2013 VA examination, he indicated that his relationship with his daughters had improved since he began receiving treatment at VA's PTSD clinic. Further, the Veteran reported that he enjoyed spending time with his grandchildren (see February 2010 VA examination report); he preferred to spend time with his immediate family or alone and he felt emotionally close with his family members (see February 2010 VA examination report); he liked spending time with his family because they were his "comfort zone" (see July 2010 VA psychology consultation report); and he attended some social events, such as family weddings (see October 2011 VA examination report). In addition, he stated that he had a close relationship with his parents. See July 2010 VA psychology consultation report. With respect to friendships, throughout the appeal, the Veteran endorsed minimal involvement in social activities outside of time spent with his family. See, e.g., October 2011 VA PTSD examination report. He also continually reported discomfort in social settings. In addition, during the July 2010 VA psychology consultation, the Veteran reported that he had no friends of his own; however, he did socialize with his wife's friends on occasion. Further, the Veteran's symptomatology has not been similar to that of the 70 percent criteria. Throughout the appeal, the Veteran demonstrated orientation to person, place, and time; coherent, logical, and goal-directed thought processes; normal speech; unimpaired impulse control; no suicidal or homicidal ideation; and appropriate appearance and hygiene. In addition, the evidence does not show that he had near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. To the extent any of the symptoms of a 70 percent rating may be shown or argued, the Board, again, emphasizes that the Veteran's PTSD has not been shown to be productive of occupational and social impairment with deficiencies in most areas, or total occupational and social impairment to warrant a higher rating. As discussed above, the Veteran's anger symptoms appear to be intermittent during times of stress rather than persistent problems. There is no also indication that he has had any of the other symptoms of the 70 or 100 percent criteria, such as suicidal ideation; obsessional rituals; illogical, obscure, or irrelevant speech; impaired impulse control; neglect of his personal appearance and hygiene; homicidal ideation; or disorientation to time or place. Moreover, the February 2010, October 2011, and May 2013 VA examiners opined that the Veteran's symptoms were not severe enough to interfere with his occupational functioning, but did appear to result in mild impairment to his social relationships. The October 2011 VA examiner further noted that any impact that the Veteran's symptoms had on his social and occupational functioning appeared mild given his ability to maintain a successful career to retirement, a second career, and a satisfactory marriage. The May 2013 VA examiner also noted that the Veteran remained employed in an appropriate, relatively isolative environment, and he maintained appropriate, although somewhat distant, social relationships with his family members. In addition, the March 2014 VA examiner opined that the Veteran's PTSD caused occupational and social impairment due to mild or transient symptoms, which decreased work efficiency and the ability to perform occupational tasks, only during periods of significant stress. Such statements are not commensurate with a rating in excess of 50 percent. Finally, the Board acknowledges that two GAF scores of 68 were assigned during the course of the appeal. See February 2010 VA examination report, July 2010 VA psychology consultation report. A GAF score ranging from 61 to 70 indicates 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, has some meaningful interpersonal relationships. See DSM-IV. After considering the totality of the evidence of record, lay and medical, the Board finds that the Veteran's symptoms more closely approximate the criteria for a 50 percent disability rating for the entire appeal period. Overall, the Veteran has not demonstrated a level of impairment consistent with the 70 percent criteria, nor have the Veteran's symptoms caused total occupational and social functioning referenced by the 100 percent evaluation criteria. Mauerhan, supra, Vazquez-Claudio, supra. The criteria for the next higher rating of 70 percent have not been met or approximated for any period in this appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Therefore, the Board finds that the Veteran's PTSD warrants a 50 percent rating, and no higher for the entire appeal period. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular 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. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Id.; see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology, which include anger, irritability, sleep impairment, and mild memory and concentration problems. As discussed above, such symptoms are contemplated by the schedular criteria set forth in the applicable diagnostic codes. Indeed, the rating criteria for mental disorders contemplate the overall effect of all of his symptomatology on his occupational and social functioning. Thus, it cannot be said that the available schedular evaluation for the Veteran's PTSD is inadequate. As discussed above, there are higher ratings available under the applicable diagnostic code, but the Veteran's disability is not productive of such manifestations. The Board further observes that, even if the available schedular evaluation for the disability is inadequate, the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The evidence shows that the Veteran retired from his post-service career as a letter carrier for the post office in 2004 and then maintained full-time employment as a driver for an auto parts supplier for nearly ten years until approximately 2013. The evidence fails to show that his service-connected disabilities have caused frequent hospitalizations or impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Finally, under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all of the service-connected disabilities experienced. However, the Court has also held that "[a]lthough the Board must consider any combined effects resulting from all of a claimant's service-connected disabilities insofar as they impact the disability picture of the disability on appeal, it lacks jurisdiction to consider whether referral is warranted solely for any disability or combination of disabilities not in appellate status, just as it lacks jurisdiction to examine the proper schedular rating for a disability not on appeal." Yancy v. McDonald, 27 Vet. App. at 496. In this case, the Veteran has not asserted, and the evidence of record does not show or suggest, any combined effect or collective impact from multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. See Yancy, 27 Vet. App. at 495 (holding that "[n]othing in Johnson changed the long-standing principle that the issue of whether referral for extraschedular consideration is warranted must be argued by the claimant or reasonably raised by the record"). Thus, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected PTSD under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Subject to the law and regulations governing the award of monetary benefits, an initial 50 percent evaluation for PTSD, but no higher, is granted. ____________________________________________ ANTHONY C. SCIRÉ, JR. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs