Citation Nr: 1644679 Decision Date: 11/28/16 Archive Date: 12/09/16 DOCKET NO. 12-24 023A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder. 2. Entitlement to a total rating for compensation purposes based upon individual unemployability. REPRESENTATION Appellant represented by: Wade R. Bosley, Esq. ATTORNEY FOR THE BOARD K. Marenna, Counsel INTRODUCTION The Veteran served on active duty from January 1964 to December 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana, which granted service connection for posttraumatic stress disorder (PTSD) and assigned a noncompensable evaluation effective December 21, 2006. In a December 2013 decision, the Board denied the Veteran's claim for an initial evaluation in excess of 30 percent for PTSD. In a September 2014 Order, based on a Joint Motion for Remand (Joint Motion), the Court of Appeals for Veterans Claims (Court) remanded the issue of an initial evaluation in excess of 30 percent for PTSD and entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU) to the Board. In a March 2015 decision, the Board granted an initial 50 percent evaluation for PTSD and remanded the claim for TDIU. In a March 2016 Order, based on a Joint Motion, the Court remanded that portion of the Board's decision that denied an initial evaluation in excess of 50 percent rating for PTSD. Development has not been completed on the remanded issue of entitlement to a TDIU. The Board finds that it is not necessary to defer adjudication of the extra-schedular issue while the TDIU claim is being addressed by the Director, compensation and Pension Service, pursuant to the remand instructions in the Board's 2015 decision. Brambley v. Principi, 17 Vet. App. 20 (2003) (noting the nature of a decision on extra-schedular consideration and a TDIU claim). However, in that case, the determining factor for the extraschedular rating was marked interference with employment. In this case, the initial element of the analysis is not met as the Board finds that the schedular criteria are not inadequate, and therefore an analysis of whether there is marked interference with employment is not required. Thus, meaningful effect of Brambley does not apply to the Veteran's case. ORDER TO VACATE VA regulations provide that the Board may vacate an appellate decision at any time upon the request of the Veteran or his representative or on the Board's own motion when there has been a denial of due process. 38 C.F.R. § 20.904 (a) (2015). In a March 2015 decision, the Board granted an initial 50 percent evaluation for PTSD and remanded the claim for TDIU. In a March 2016 Order, based on a Joint Motion, the Court remanded that portion of the Board's decision that denied an initial evaluation in excess of 50 percent rating for PTSD. Accordingly, that portion of the Board's March 2015 decision that denied the claim of entitlement to an initial rating in excess of 50 percent for PTSD is vacated and a new decision will be entered as if that portion of the March 2015 decision had never been issued. FINDINGS OF FACT 1. Prior to December 31, 2014, the Veteran's service-connected posttraumatic stress disorder (PTSD) symptoms included anxiety, irritability, suicidal ideation, hypervigilance, avoidance, nightmares, intrusive thoughts, and occupational and social impairment with reduced reliability and productivity, resulting in no worse than moderate social and occupational impairment. 2. From December 31, 2014, the Veteran's service-connected PTSD symptoms include anger, irritability, impaired impulse control, hypervigilance, depression, and occupational and social impairment with deficiencies in most areas, resulting in severe social and occupational impairment. CONCLUSIONS OF LAW 1. Prior to December 31, 2014, the criteria for an initial rating in excess of 50 percent were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 2. From December 31, 2014, the criteria for a staged, initial rating of 70 percent, but no more, for the Veteran's PTSD, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015); Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2015). The Rating Schedule is primarily a guide in the evaluation of disabilities 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 (2015). The Veteran's service-connected PTSD has been assigned a 50 percent disability rating pursuant to the criteria of Diagnostic Code 9411, which is included under the General Rating Formula for Rating Mental Disorders. 38 C.F.R. § 4.130. According to the General Rating Formula for Rating Mental Disorders, a 50 percent disability rating is warranted 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, for example, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted when there is objective evidence demonstrating 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; and the inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A maximum 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: 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 and place; memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the evidence, the Board also considers the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.) (DSM-IV). Although current mental health evaluations no longer use this assessment of functioning under the new DSM-5 criteria, the Veteran's case was certified to the Board prior to VA's amendment to the regulations adopting the new criteria, and accordingly, the Veteran's claim is evaluated under the DSM-IV criteria, which does consider GAF scores. Compare DSM-IV at 46-47, with DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (5th ed.) (DSM-5); see also 38 C.F.R. § 4.125, amended by 79 Fed. Reg. 45099 (effective Aug. 4, 2014). A GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally reflects that a person is functioning pretty well, and has some meaningful interpersonal relationships. DSM-IV, at 46-47. A GAF score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. Id. A GAF score of 41-50 is assigned where there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals), or any serious impairment in social, occupational, or school functioning (e.g., no friends, inability to keep a job). Id. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record to this time period and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. 38 C.F.R. § 4.126 (2015). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned. The percentage evaluation is to be based on all of the evidence that bears on occupational and social impairment. Id. Prior to December 31, 2014 A March 2008 VA examination report reflects that the Veteran reported he felt anxious and panicky, and did not like to be confined. He reported having social relationships with his mother, wife, and friends. His leisure activities included building "hot rods" and attending car shows. The mental status examination in March 2008 revealed that the Veteran was oriented to person, time, and place. His thought process and thought content were unremarkable, and he reported no delusions. His immediate memory was mildly impaired. His PTSD symptoms included recurrent distressing dreams of traumatic events, avoidance of activities that arouse recollections of trauma, irritability or outbursts of anger, hypervigilance, and exaggerated startle response. The Veteran reportedly worked full-time as a mechanic, and had lost approximately two weeks from work in the previous 12-month period due to illness. The March 2008 VA examination report noted the Veteran did not have suicidal thoughts. The evidence shows that in a March 2009 statement, the Veteran reported experiencing thoughts of suicide. He stated that the March 2008 VA examiner had "recorded incorrect information concerning presence of suicidal ideation." A September 2009 private psychological evaluation revealed that the Veteran was casually dressed, and his hygiene was adequate. His mood was somewhat dysphoric, and his affect was appropriate to the content of what he said. The Veteran described flashbacks and intrusive thoughts, and reported that his only friends were Vietnam Veterans. He reported having a confinement problem, and becoming panicky when stuck in traffic. He also reported feeling detached from others. He reported having impaired sleep and described becoming angry due to his "short fuse." His wife also described the Veteran's impaired concentration, his hypervigilance, and his irritability. His wife stated that she felt the Veteran was detached from her and their kids. The Veteran completed a "Penn Inventory" questionnaire that indicated he was "more easily distracted than ever," and that he "can't concentrate as well" as he used to. He reported intrusive memories, sleep and memory problems. The private psychologist in September 2009 diagnosed PTSD and assigned a GAF score of 51. At a hearing before the Board in September 2009, the Veteran testified to having nightmares, intrusive thoughts, and panic attacks when stuck in traffic. He reported that he avoided war-type movies and violence. The Veteran testified that he was basically a loner, and did not like to work around people. He stated that he avoided crowds, and described incidents of irritability and outbursts of anger. The Veteran also described ongoing anxiety. The Veteran's wife testified that the Veteran had very few friends; and that the Veteran often stayed in the garage, which was "his refuge." His wife testified that the Veteran would not leave his home without an oxygen tank and a Xanax, his "security blanket." A March 2010 VA examination report reflects that the Veteran's PTSD symptoms included episodic depression that was moderate to severe. The Veteran complained of constant anxiety, that was at times severe. The Veteran reported he had been prescribed Xanax. PTSD symptoms in March 2010 included severe flashbacks, two-to-three times a week; severe nightmares; recurring feelings of severe trauma, two-to-three times a week; moderate-to-severe avoidance of thinking, feeling, and talking about experiences in Vietnam; moderate-to-severe avoidance of activities that arouse recollections of trauma; moderate-to-severe inability to recall important aspects of trauma; severe diminished interest in activities; moderate feelings of detachment from others; and moderate-to-severe restricted range of affect. These symptoms occurred daily, unless otherwise noted. The Veteran also described difficulty sleeping, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response. The mental status examination in March 2010 revealed no objective findings of impairment of thought process or communication, no persistent delusions or hallucinations, no inappropriate behavior, and no current suicidal or homicidal thoughts or intent. The examiner reported that the Veteran was treated for a suicide attempt in 1977. The examiner found that the Veteran was able to maintain minimal personal hygiene and tend to other basic activities of daily living. The Veteran was oriented to person, place, and time. There was no objective evidence of memory loss or impairment, or of obsessive or ritualistic behavior that interfered with routine activities. His rate and flow of speech were normal. The examiner noted that the Veteran had moderate-to-severe panic attacks that occurred approximately two times a week, for example, when caught up in traffic, and that the Veteran avoided certain situations. It was noted that the Veteran had depression two times a month that was moderate to severe. In response to how depression interfered with employment and social functioning, the examiner noted the Veteran was retired. The Veteran's anxiety, described as moderate-to-severe, occurred daily. The report noted the anxiety interfered with employment and social functioning because he "may avoid certain situations." The examiner found that the Veteran's sleep impairment was moderate-to-severe, with frequent awakening throughout the night and with early morning awakening, and caused daytime fatigue, which occasionally required the Veteran to nap. The March 2010 examiner also noted that the Veteran had a boss who accommodated the Veteran's PTSD-related need to be away from others, etc., and that when the Veteran's boss retired, so did the Veteran. The examiner concluded that there were PTSD signs and symptoms that were transient or mild, which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The Veteran's PTSD symptoms required continuous medication, and were severe enough to interfere with occupational and social functioning. The Axis I diagnosis was PTSD, and a GAF score of 65 was assigned. A November 2013 statement from the Veteran's former employer noted that, "[the Veteran] had some difficulties getting along with other people. We had him in a position where there was limited interaction with people." Based on the evidence of record prior to December 31, 2014, the Board finds that a rating in excess of 50 percent is not warranted. The Veteran's overall symptoms of PTSD were consistent with occupational and social impairment with reduced reliability and productivity. The totality of the evidence shows the Veteran had mild to moderate symptoms of PTSD prior to December 31, 2014, that resulted in occupational and social impairment with reduced reliability and productivity. In so finding, the Board has considered all of the evidence that bears on occupational and social impairment, to include the medical findings and the lay statements of record. With regard to social impairment, the March 2008 VA examination report indicated the Veteran had social relationships with his mother, wife and friends. He did not have any delusions and his thought content was unremarkable. The Board has considered the Veteran's statement in March 2009 that he had suicidal ideation. However, he did not have deficiencies in most areas, such as work, family relations, judgment, thinking or mood. The Veteran's symptoms of PTSD included having trouble concentrating, sleep impairment, and irritability. The Veteran's symptoms of PTSD prior to December 31, 2014, included depressed mood, anxiety, panic attacks, chronic sleep impairment, nightmares, and panic attacks. The Veteran was consistently oriented to person, place and time. Regarding occupational impairment, the March 2010 examiner concluded that there were PTSD signs and symptoms that were transient or mild and would only result in decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The Veteran did not report any symptoms of obsessional rituals, illogical, obscure, or irrelevant speech, spatial disorientation, or neglect of personal appearance and hygiene. The March 2010 VA examination report noted the Veteran experienced depression approximately twice a month. Panic attacks were noted to have occurred approximately two times a week only in certain situations, for example, when caught up in traffic. There was no evidence of memory loss or obsessive or ritualistic behavior. The Veteran was consistently able to maintain his personal appearance and hygiene. Additionally, the September 2009 private psychologist assigned a GAF score of 51, indicating moderate symptoms or moderate difficulty in in social or occupational functioning. DSM-IV, at 46-47. The GAF score of 65 in March 2010 indicates mild symptoms or some difficulty in social or occupational functioning. Id. Accordingly, the Board finds that a rating in excess of 50 percent for PTSD is not warranted, prior to December 31, 2014. From December 31, 2014 A December 2014 private examiner found that the Veteran's impairments in occupational and social functioning are "very severe." The report noted that the Veteran resisted going to the VA for treatment of his PTSD until very recently. The Veteran and his wife reported that in April 2014, and in the preceding few months, the Veteran had been more irritable and short-tempered and was struggling with anxiety. The Veteran reported having nightmares, intrusive thoughts, avoidance of war-related movies, and avoidance of crowds and tight spaces. He reportedly did not drive on the interstate for fear of being trapped by an accident. The mental status examination revealed that the Veteran was very casually dressed, he was bearded, had longish grey hair, and missing several teeth. The Veteran was noticeably guarded, and the examiner noted that he gave the distinct impression that he was holding back with respect to how difficult PTSD and depression have made his life. The Veteran's mood was anxious and depressed, and his affect was blunted and dour, which reflected his mood. Eye contact was penetrating, but fleeting. Reality testing was good, and flow of thought was good and uninterrupted. The psychologist noted that the Veteran admitted that he was "wound up," and had not slept well the night before because of worry about his appointment. The Veteran did not "like to appear weak," and was reluctant to admit to difficulties related to PTSD. The Veteran reported that he had worked as a mechanic, and that his boss had let him "go off by [him]self" and that "nobody messed with [him]" at work. The Veteran admitted to being irritable and quick to fly off the handle, and that he lost his temper; and that when his boss was getting ready to retire, the Veteran knew that "[his] days were numbered." The examiner found that the Veteran was alert and oriented times four. Frank hallucinations were denied, although the Veteran believed that he knew at times what his mother might say about his activities and choices. He was not paranoid. His remote memory was good. He took psychotropic medications, but refused antidepressants. The psychologist noted that the Veteran described intrusive memories and flashbacks that were recurrent and involuntary. He also described traumatic nightmares. The Veteran avoided the interstate for fear of being caught in a traffic jam. His sense of disillusionment and being alienated from others was profound. He did not permit anyone to get close to him. At the examination, the Veteran's wife explained that the Veteran became angry "really, really fast" for no reason; and that it was hard for him to make friends, and that he kept his distance from friends. On a typical day the Veteran went into the garage to work on projects, would return to check on her and to eat lunch, and then went back to the garage until dark. His mind wandered all the time, and she had to stay on him to finish a project. She reported that the Veteran yelled in his sleep, and had flashback episodes multiple times a day. He also was hypervigilant about her safety, and he resisted treatment for PTSD. She did not think anything made the Veteran happy. Following a psychometric assessment, the diagnoses included severe PTSD and major depressive disorder. A GAF score of 51 was assigned. The private examiner stated that the Veteran's impairments were "very severe." The examiner stated that the Veteran's anger related to PTSD, to include unprovoked irritability, had placed the most severe limitations on the Veteran's ability to function occupationally and socially. The private examiner stated that "[e]verything the veteran and his wife told me during my interviews points to continuous impairment at this level since at least 2006 with an inability to be gainfully employed due to his PTSD since he retired in October 2008." In a January 2015 report, a private vocational expert opined that it was "as likely as not" that the Veteran was unable to secure or follow a gainful occupation as a result of his service-connected disabilities. The vocational expert noted that the Veteran had intrusive thoughts on a daily basis, and that he "faded out" and lost focus about twice a day. The Veteran was reminded of his combat experiences daily, and had episodes of anger from standing in line at a store to road rage. The Veteran began projects but did not complete them. In a June 2015 statement, the Veteran stated that when he said he worked building hot rods, it was a hobby. He stated that the hobby kept him busy because if he was idle, he had more time to think. He also stated that "[w]hen I was at the school maintenance facility, I had a very understanding boss." He stated that when his boss was going to retire, "I knew I had to leave also as my PTSD symptoms would have got me fired and could have resulted in me getting physically violent with others." The probative evidence of record establishes that from December 31, 2014, the Veteran's PTSD most nearly approximates the criteria for a 70 percent rating. 38 C.F.R. §§ 4.7, 3.400 (2015); Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD has resulted in symptoms of anxiety, irritability, angry outbursts, hypervigilance, avoidance, difficulty sleeping, intrusive thoughts, and social isolation. With regard to occupational impairment, the December 2014 private psychological examination indicates the Veteran reported he was irritable and quick to lose his temper. The private psychologist found the Veteran's anger related to PTSD, to include unprovoked irritability, had placed the most severe limitations on the Veteran's ability to function occupationally and socially. The January 2014 private vocational expert found the Veteran was unable to secure or follow a gainful occupation as a result of his service-connected disabilities. With respect to social impairment, the evidence shows the Veteran felt detached from other people. He noted having irritability and preferred to be alone. The Veteran's wife told the December 2014 psychologist that he became angry quickly for no reason and that it was hard for him to make friends. The Veteran reported having flash backs and traumatic nightmares. The December 2014 psychological examination showed a GAF score of 51, indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning. However, the private psychologist described the Veteran's impairments in occupational and social functioning as "very severe." As noted above, the Board must consider all the pertinent evidence of record to this time period and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Although the December 2014 private examiner stated that the evidence pointed to continuous impairment at this level since at least July 2006, with an inability to be gainfully employed due to his PTSD since he retired in October 2008, the medical evidence and lay statements of record during the appeal period shows otherwise. Moreover, the private psychologist did not review the evidence of record when formulating this conclusion. Based on the Veteran's overall symptoms from December 31, 2014, including constant, severe anxiety, depression, sleep problems, and avoidance, and with consideration of the December 2014 examiner's opinion that the Veteran's impairments in occupational and social functioning are "very severe," the Board finds that the PTSD symptoms are consistent with occupational and social impairment with deficiencies in most areas, warranting a 70 percent rating. The Board finds that the criteria for a disability rating of 100 percent have not been met or more nearly approximated at any time during the appeal period. The evidence during the appeal period does not show that the Veteran experienced total occupational and social impairment, or that he displayed symptoms of gross impairment in thought processes or communication; grossly inappropriate behavior; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The evidence does not indicate the Veteran had any hallucinations or disorientation. Although the Veteran reported having suicidal ideation during the appeal period, there is no evidence he was in persistent danger of hurting himself or others. Extraschedular Consideration Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2015). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. Nonetheless, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321 (b) (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed by either the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is considered adequate, and no referral is required. The Veteran's service-connected PTSD is evaluated as a mental disorder pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his service-connected PTSD. Id. Prior to December 31, 2014, the Veteran's service-connected posttraumatic stress disorder (PTSD) symptoms included anxiety, irritability, suicidal ideation, hypervigilance, avoidance, nightmares, intrusive thoughts, and occupational and social impairment with reduced reliability and productivity, resulting in no worse than moderate social and occupational impairment. Beginning December 31, 2014, the Veteran's service-connected PTSD symptoms include anger, irritability, impaired impulse control, hypervigilance, depression, and occupational and social impairment with deficiencies in most areas, resulting in severe social and occupational impairment. When comparing these disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by the disability ratings assigned herein. Evaluations in excess of the disability ratings are provided for certain manifestations of the Veteran's PTSD, but the medical evidence demonstrates that those manifestations are not present in this case. The criteria for a 50 percent disability rating prior to December 31, 2014, and a 70 percent rating thereafter, reasonably describe the Veteran's disability level and symptomatology. Consequently, the Board concludes that the schedular evaluations are adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no distinct periods of time during the appeal period other than those assigned herein, when the Veteran's service-connected PTSD varied to such an extent that a rating greater or less than those assigned would be warranted. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). Finally, in reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against a rating in excess of 50 percent prior to December 31, 2014, and of 70 percent thereafter for the Veteran's service-connected PTSD at any time during the appeal period, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial rating of 50 percent for PTSD prior to December 31, 2014, is denied. An initial rating of 70 percent for PTSD from December 31, 2014, is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs