Citation Nr: 1645012 Decision Date: 11/30/16 Archive Date: 12/09/16 DOCKET NO. 15-22 640 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD S. Kim, Associate Counsel INTRODUCTION The Veteran had active duty in service from September 1960 to May 1964. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2014 issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In a June 2015 statement, the Veteran requested a hearing before a Decision Review Officer (DRO). However, a June 2016 statement reflects the Veteran's desire to withdraw such hearing request. 38 C.F.R. § 20.704(e) (2015). Therefore, there is no outstanding hearing request. In June 2016, the Board remanded the claim for additional development. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDING OF FACT For the entire appeal period, the Veteran's PTSD results in occupational and social impairment with reduced reliability and productivity, due to such symptoms as depressed mood, anxiety, sleep impairment, periodic nightmares, episodic suicidal ideation, and difficulty in establishing and maintaining effective relationships, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas or total occupational and social impairment . CONCLUSION OF LAW The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). No notice or due process deficiencies have been alleged by the Veteran or his representative. With regard to duty to assist, the Board is cognizant that the Veteran has reported being in receipt of Social Security Administration (SSA) benefits since 2000, as reflected in VA examination reports dated in November 2010 and August 2016. As the record indicates that the SSA benefits were awarded due to the Veteran's back disability, and the Veteran does not otherwise claim that such records are relevant to the instant increased rating claim for PTSD, the Board finds that a remand of this appeal to obtain SSA records is not warranted. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). As a final note, any records associated with the SSA claim II. Analysis Applicable Laws and Regulations Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, are expected in all instances. 38 C.F.R. § 4.2. PTSD is evaluated under VA's General Rating Formula for Mental Disorders. Under the formula, a 50 percent 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 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. Id. A 70 percent rating is warranted where 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; 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. Id. A 100 percent rating is warranted when there is 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. Id. The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. The Board observes that the newer DSM-V has now been officially released. An interim final rule was issued on August 4, 2014, that replaced the DSM-IV with the DSM-V. 79 Fed. Reg. 45093 (Aug. 4, 2014). However, the provisions of the interim final rule apply to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. Thus, the newer DSM-V does not apply to the present case. Under DSM-IV, a GAF score of 71 to 80 indicates that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). A GAF score 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. A GAF score of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. DSM-IV; 38 C.F.R. §§ 4.125, 4.130; see Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). 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 the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). As the United States Court of Appeals for the Federal Circuit has held, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms [,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e. "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in "most areas." Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Factual Background Historically, the Veteran filed the instant increased rating claim for PTSD in October 2013. Pertinent evidence as to the current level of severity of the Veteran's PTSD includes VA examinations dated in May 2014 and August 2016, statements from the Veteran and his sister, and VA treatment records dated through September 2016. An April 1, 2013 VA treatment note indicates that the Veteran was "humiliated when out with girlfriends and has an accident" related to his stress incontinence problems. Also noted was that the Veteran had been "compulsively drinking coffee and tea with cream/sugar" which "added to his stress incontinence." The Veteran expressed that he was "pleased that his brother, who is a Washington U graduate, stopped drinking five fifths week when he went into the Nursing home." The Veteran also described "feeling a strong responsibility to take care of [his brother and sister]." The treating physician noted that the Veteran was feeling "dysphoric" about "turn[ing] 72" and that he was also in mourning for his daughter, who was "murdered by a new boyfriend shortly after a divorce," and his deceased former spouse. No new risk factors relevant to suicide or homicide were reported at this time, and the Veteran did not appear to be at imminent risk to harm himself or others. An April 22, 2013 VA treatment note reflects the Veteran's report that "[t]hree ladies in his apt building are all cooking for him and bringing free meals to his apt . . . . but [that he] doesn't want to choose from amongst the three ladies; all of whom seem to be auditioning to marry him." The Veteran stated that he obtained a driver's license and now hoped to purchase a car, noting that he was "quite isolated in his apt and rarely goes out." The Veteran also stated that his brother was going through marital discord with his wife and that his brother "depends a lot on the [Veteran] and his sister." The treating physician also indicated that the Veteran's strengths included "[e]xpressed desire/motivation for change," ability to "identify when [he] need[s] extra help," "education," and "previous job success." Also noted were complaints of depressive symptoms, to include "low mood," and the Veteran's goals to reduce sleep disturbance and improve mood. A May 2013 VA treatment note indicate that the Veteran complained of having "a lot of nightmares as the 4th of July approaches" during which his "best friend was stabbed/died in his arms 50 years ago on the 4th of July." The Veteran reported that his sister was "trying to get him to join family events when he doesn't feel up to it." A May 28, 2013 VA Social Work treatment note reflects that the Veteran was assessed for risk of suicide and that he denied being suicidal or homicidal. The Veteran was "thankful for today's session ." A June 2013 VA Social Work treatment note reflects that the Veteran denied suicidal or homicidal ideations. The licensed clinical social worker observed that the Veteran appeared to be "managing stress and anxiety well" with "[g]ood coping skills for ptsd symptoms." Continued supportive therapy once a month was recommended. In an August 2013 VA treatment note, the treating psychologist noted that the Veteran was "feeling remarkably better" after resolution of a mass in his lungs. The Veteran reported that he had been "talking with his Pastor and his sister" and that "the congregation's prayers were a factor in his healing." The Veteran expressed that "he should become more involved in the Church, perhaps do some volunteer work for the Church or for the VAMC." The treating physician noted that the Veteran was sleeping poorly due to urinary urgency. On mental status examination, mood/affect were found to be normal, delusions or hallucinations were absent, suicidal/aggressive ideation were absent, and the Veteran was found to be alert and oriented with good concentration. A September 2013 VA treatment note reflects that the Veteran was feeling better and that he was "planning to purchase a laptop computer with the help of his niece." The Veteran also expressed that he was "eager to learn after watching little kids in his building and in the family use the computer very easily." He indicated that he was experiencing nightmares and intrusive recall of his friend's stabbing death. An October 25, 2013 VA Social Work treatment note indicates that the Veteran reported feeling depressed and having problems with sleeping. The Veteran reported that "constant worries and intrusive thoughts and images of his traumatic experience in the military continue to cause him distress." The Veteran denied suicidal or homicidal ideations at the time. The licensed clinical social worker noted that depression level has increased, but that the Veteran was not at risk for suicide. In an October 25, 2013 VA treatment note, the treating psychologist noted that the Veteran was "upset with his niece" because she "upsets his sister and is always asking everyone for money." The Veteran was "more independent again and driving himself to the grocery store and to see his brother." On mental status examination, the Veteran was found to be "well groomed, animated" and with thoughtful, logical speech, normal thought content, absent suicidal ideation, absent violent ideation, oriented as to time, place and person, intact recent/remote memory, intact attention/concentration, goal directed language, and intact fund of knowledge as a college graduate. The Veteran's mood and affect were found to be "generally euthymic, animated, playful." In a March 2014 correspondence, the Veteran's sister wrote that they were "very close in years and family relations." She further wrote that they "depend on each other greatly, esp[ecially] since [their] loss of both of [their] parents." His sister wrote that the Veteran "tries to lead and advise [his siblings] but his temper is very short and explosive," although he "apologizes and tries to make up for the disruptions." Furthermore, she stated that the Veteran did not know "how to control his anger and stop the problem before it goes out of control" and that he wanted "better relationships and less drama in his life." A May 2014 VA examination report indicates that the Veteran retired in 2000 and that he had a history with "alcohol, cocaine, and cannabis use rather heavily." The Veteran expressed "some significant dysphoria secondary to 3 divorces and the murder of his daughter," which "exacerbate[d] the Veteran's drinking." The Veteran reported that he was not currently using alcohol or drugs. As for suicidal and homicidal ideation, the Veteran reported that he "has moved beyond those kinds of behaviors at the present." The examiner noted that the Veteran has been living in a nursing home for about 6 weeks, secondary to a falling incident and "some other health concerns." The Veteran reported that he lived in an apartment by himself prior to the nursing home and that he "spent time going to the Missouri History Museum and to Forest Park when he had a car for transportation." The Veteran also reported that he did his own shopping, "going out 2 to 3 times per week" and that he "mostly was eating out and doing very little cooking for himself." The Veteran also reported that he went out to eat with his sister and brother, who was a resident in the Soldier's Home in St. Louis. The Veteran reported that he had no regular sleep routine, claiming that he "gets 4 to 5 hours sleep duration on average night and gets most of it during the time frame approaching morning." The Veteran described his sleep as "restless with multiple awakenings." With regard to his dreams, the Veteran stated that if he had a dream, it meant that he was "getting good sleep." The examiner noted that the Veteran could not indicate "dreams that he clearly remembered. Shortly before his hospitalization due to the falling incident, the Veteran had "gone back to church attendance and was beginning . . . to wear a suit again as he did when he worked." The Veteran also reported that he had memories about his friend who died during service and stated that it was "more or less 'stupid' incident." The examiner noted the Veteran's report that 'it's history and [he has] moved on' and that the Veteran "denied having made decisions based on it." The examiner noted that "of greater emotional salience are [the Veteran's] memories of the murder of his daughter. . . ." Flashbacks were denied. The examiner noted that he did not observe "gross loss of interest in his environment at large" as the Veteran reported "going out with his brother and sister . . . within the restrictions of his physical condition and resources." The examiner further noted that while the Veteran "describes himself as a loner," he described himself as a 'pretty much a people person,' and that he "still remained occasionally sexually active with medical intervention." The examiner then noted that the Veteran "has the capacity for positive emotions about things that interest him" despite "some ongoing resonant depression." The examiner commented that notwithstanding his depression, the Veteran "does not feel useless, helpless, or hopeless and his self-esteem seems relatively intact." Appetite appeared to be "well-preserved" and low mood was "virtually the only significant symptom." No evidence of paranoia was reported on his last examination. The examiner noted the Veteran's report that he did not "see himself as irritable although he acknowledge[d] that his sister perceives him so." The examiner observed that "easy arousability to irritation was observable in this interview." There was no report of excessive startle. Concentration was not a clear complaint, as the Veteran reported that he could "read through the AARP magazine and find it interesting and read through the entire thing usually in 1 or 2 sittings." Anomalous sleep behavior was noted. During mental status examination, the examiner observed that the Veteran was dressed in dark blue hospital pajamas and confined to a wheelchair, while noting that grooming and hygiene were "hospital-typical." Eye contact was found to be good. Speech was within normal limits as to flow, rate and prosody. Thought train was occasionally circumstantial. Mood was generally euthymic with appropriate affect and appropriate humor and risibility. The Veteran appeared oriented as to time, place, and person, without obvious evidence of psychosis. The examiner observed that "the Veteran generally was forward looking and had distinct plans for the future" and that he "hope[d] to find 'a female [he] can trust' with whom he can have an enduring friendly relationship and share some activities." Furthermore, the examiner noted that the Veteran's "most active complaints [were] about his general aging and his need to adapt and recover and attempt to return to independent living" and that his condition "appear[ed] uncomplicated by alcohol or drug abuse." The examiner concluded that the Veteran did not meet the diagnostic criteria for PTSD under DSM-V and provided a diagnosis of depressive disorder, not otherwise specified. The examiner noted that no opinion as to "work adaptation" was given because such was not the examiner's expertise. A May 30, 2014 VA treatment note indicates that the Veteran's urinary drug test results were positive for cocaine and that he was "upset when asked about it" because such was not "relevant to his care." The Veteran expressed that he was "less anxious" with regard to "depression/PTSD/anxiety." A May 2015 VA Social Work treatment note reflects the Veteran's report of "feeling depressed and lonely" and that he "wish[ed] he had a female companion and be intimate with as he really misse[d] that." The licensed clinical social worker noted the Veteran's report that he 'had a friend who he does things with but he is not attracted to her." The Veteran considered "going and start[ing] exercising at the YMCA since he was given medical clearance to do this" and denied suicidal and homicidal ideations. The licensed clinical social worker recommended attending senior citizen center and church to increase socialization, and the Veteran was found to be "receptive and motivated." A May 2015 VA treatment note reflects the Veteran's report that he was feeling better physically, but that he was "now reluctant to take out women because he [was] embarrassed about his lap scar." The treating psychologist further noted that the Veteran was "worried about his brother in law who fell and broke his leg . . . ." The treating psychologist observed that the Veteran appeared "well groomed, labile" and exhibited well-spoken speech, linear thought processes/associations, no reported psychotic symptoms as to thought content, absent suicidal ideation, absent violent ideation, grossly intact judgment and insight, orientation as to time, place, and person, grossly intact memory, good attention/concentration, wide vocabulary in language, intact fund of knowledge, and labile mood and affect, although affect was found to be congruent to various moods expressed. In his substantive appeal (via VA Form 9) dated in June 2015, the Veteran wrote that he was receiving treatment for his "suicidal thoughts" from his social worker and psychiatrist. A December 2015 VA treatment note indicates that the Veteran continued to grieve his daughter and his parents, and that Christmas was particularly difficult for him due to many losses. The Veteran reported that he was planning to go visit his brother in the "MO Vet's home" that day. The treating psychologist noted that the Veteran "continue[d] to wish he had another girlfriend" and that he appeared to be "well groomed, animated." Speech was found to be "gregarious" as a "former salesman" and thought processes were found to be linear. Suicidal ideation and violent ideation were absent. The Veteran was found to be oriented and memory was grossly intact. Attention and concentration were found to be adequate and language was to be of normal usage. The Veteran's fund of knowledge was found to be intact. Mood and affect were observed to be "dysphoric, irritable." A January 2016 VA treatment note indicates that the Veteran was "in communication with his ex-wife, a nurse in Chicago and [was] thinking of trying to move back there and reconcile with her." Also noted was that his sister and her husband were ill and that the Veteran was "trying to help them . . . and visit his brother in a [nursing home] but this [was] too much for him." The treating psychologist observed that the Veteran appeared to be well groomed, "anxious, near tears at times." Speech was found to be at normal rate and pace. Thought processes were linear, there were no reported psychotic symptoms as for thought content, suicidal and violent ideation were absent, judgment and insight were "at usual outpt baseline," memory was grossly intact, attention/concentration were adequate, language was of normal usage, fund of knowledge was intact, and mood and affect were described as "labile, near tears at times." February 15, 2016 and February 18, 2016 VA treatment notes document that suicide screen findings were negative and that the Veteran denied having thoughts of harming self or others. A February 25, 2016 VA Social Work treatment note reflects the Veteran's report that he was "doing fine with his ptsd and depression symptoms" and that "[t]he medications he is on [were] very helpful," although he expressed "some stress due to health problems." The Veteran reported that he had some problems with a bump behind his head and an eye infection and that he had taken some sick leave from his volunteer job at a substance abuse facility as result. He stated that "doing volunteer work has been very beneficial for his mental health and he has been learning about addictions" and that he has been "try[ing] to stay busy and continue to see and interact with his sister and brother-in-law." He denied suicidal and homicidal ideations at this time. A February 25, 2016 VA treatment note reflects that the Veteran was seen by his treating psychologist, who noted that the Veteran was treated earlier that day for a bump on his head. The treating psychologist noted the Veteran's report that he "likes the home care lady who cleans his bathroom" and that he "thinks she may be angling for a romantic relationship." The Veteran expressed that he was "hopeful but [was] biding his time." There was no reported substance use at this time. The Veteran expressed "worries about his sister and how they get along together." The treating psychologist observed that the Veteran was well groomed, "wearing extremely expensive knee high laced, European made black leather boots," while noting that they were "a gift from a now deceased former girlfriend." The Veteran was found to be "animated" and oriented. Speech was found to be with normal articulation, thought processes were linear, suicidal and violent ideations were absent, judgment and insight were grossly intact, memory was grossly intact, attention/concentration was good, language was of normal usage, fund of knowledge was intact, and mood and affect were "relatively euthymic with congruent affect." A March 2016 VA treatment note indicates that the Veteran "had an enjoyable 75th birthday celebration with his sister and brother in law at a steak house . . . ." The Veteran continued to express concerns about his urinary incontinence. The treating psychologist noted that the Veteran continued to "hope he will meet a compatible lady." The treating psychologist found the Veteran to be well groomed, "animated, chatty." The Veteran's speech was "rambling, a bit circumstantial." Thought processes were generally goal directed without psychotic symptoms. Suicidal and violent ideations were absent. The Veteran was found to be oriented with grossly intact memory, good attention, language with normal usage, intact fund of knowledge, and "relatively euthymic, animated" mood and affect, although his anxiety about upcoming surgery was noted. A May 2016 VA Social Work treatment note indicates that the Veteran reported "increased anxiety due to upcoming surgical procedure" for his incontinence problems and that he was losing sleep. The licensed clinical social worker noted that after the session, the Veteran reported feeling "more confident about his upcoming procedure . . . and [was] optimistic about it." Suicidal and homicidal ideations were denied at this time. In VA treatment notes dated in June 2016, the treating psychologist noted the Veteran's reports of intrusive recall of his friend die due to a stabbing incident on the 4th of July approximately 40 years ago. Suicidal and homicidal ideations were absent during this time. The Veteran was found to be well groomed with linear thought processes and intrusive recall of past trauma as for thought content. Memory was found to be grossly intact with adequate attention. Mood was found to be "labile, anxious, near at times when discussing past trauma. In a July 19, 2016 VA treatment note, the Veteran reported that "the anniversary of his friend's death was most upsetting and triggered more nightmares/lower mood" and that he has been driving his sister to see her husband because she was too ill to drive. The Veteran also reported that his sister has been "trying to fix up [the Veteran] with nurses" and that he has been "eyeing them but hasn't taken any one out yet." The Veteran expressed that he continued to be "worried about his many health issues," to include a lump on the left tibia and a ventral hernia. The Veteran was found to be well groomed, "animated/friendly," with normal rate/pace speech, linear thought processes, no reported psychotic symptoms as to thought content, absent suicidal and violent ideations, grossly intact judgment and insight, orientation, grossly intact memory, good attention/concentration, normal usage language, intact fund of knowledge, and "labile/dysphoric then playful/animated" mood and affect. In a July 19, 2016 VA Social Work treatment note, the Veteran reported that he experienced "some stress due to his brother in law being sick and he has had to be the driver as his sister was not able to drive due to the type of medications she takes." The Veteran reported that he was recovering from the 4th of July as it "always triggers memories and feelings related to his traumatic event in the military." He stated that his health was better and "overall feeling pretty good." An August 2016 DBQ report provides that the Veteran has or has had a diagnosis of PTSD and that he was currently diagnosed with Major Depressive Disorder, Recurrent, Moderate. The examiner indicated that the Veteran remained single and lived alone, and that he did not have any children. The examiner noted that while the Veteran was unable to identify friends outside of his immediate family and spent most of his time alone, he continued to maintain contact with his brother and sister. The Veteran reported "a reduction in social activities," including "volunteer/church activities," due to his "increasingly severe health problems and because he '[did not] feel like doing things.' The Veteran reported that mental health treatment "reduce[d] his level of anxiety and irritability and improve[d] his mood." The examiner pointed out that the Veteran's mental health treatment records were "predominantly focused on treatment of depressive spectrum symptoms, sleep disturbance, irritability/worry about health conditions, lack of interest/enjoyment of activities, sadness over lack of social connection ," "with mention of PTSD spectrum symptoms (intrusive thoughts/nightmares) typically only near the anniversary date of his friends date." Also noted was that the Veteran remained unemployed and relied on Social Security and VA pension benefits. The examiner further noted that there was no history of psychiatric hospitalizations or history of suicidal ideation or suicidal attempts since the last evaluation. The examiner noted that the Veteran "admitted to sporadic, short lived SI/HI" but that he denied "formulation of plan, intent, or any attempts" and indicated that "[r]elationship with family member appears to be the strongest protective factor." The examiner indicated that the Veteran denied feelings of hopelessness and auditory/visual hallucinations. The Veteran also denied panic attacks, although he experienced chronic worry with regard to his health condition and relationship status. The Veteran reported that his mood was "predominantly depressed and apathetic, noting low levels of interest/enjoyment in activities." The Veteran also reported suffering from sleep difficulties, low energy, and low appetite, although the examiner noted increased weight over the last two years. The Veteran stated that he maintained "reoccupation/rumination on the growing number of chronic health conditions and the functional impact they have on his life." The examiner noted that the Veteran's treatment records indicated that his complaints of intrusive thoughts and nightmares were "chief complaints at the anniversary of his friend's death." The examiner further remarked that the Veteran was "unable to clearly identify triggers for memories other than anniversary and speaking of event." The Veteran denied any ongoing legal problems or substance or illicit drug abuse since the last evaluation. On mental status examination, the Veteran was found to be oriented, "clean, well groomed, and casually dressed." Speech was slow with no evidence of word finding. Answers to questions were frequently "tangential" but were consistent with information found in the clinical record. There was no evidence of "loosening of associations" and affect was found to be "broad." The Veteran denied any suicidal or homicidal ideation. Insight and judgment appeared intact. The examiner observed that the Veteran was "cooperative, easy to engage, but slightly difficult to focus." The examiner further noted that while the Veteran had "hx of vague short lived SI with no formulation of intent or plan," protective factors included his connections to his sister and brother and religious beliefs. The examiner commented that, the diagnosis of PTSD, "in the presence of symptoms consistent with a depressive disorder, is complicated by the symptoms overlap, between [Major Depressive Disorder] and PTSD." The examiner then concluded that based on clinical records, "the Veteran's clinical presentation is most consistent with a Major Depressive Disorder, Recurrent Moderate." Schedular Analysis Following a review of the relevant evidence of the record, the Board finds that a rating in excess of 50 percent for the Veteran's PTSD is not warranted for the entire appeal period. In this regard, the Board finds that such symptomatology, to specifically include the Veteran's depressed mood, anxiety, sleep impairment, periodic nightmares, episodic suicidal ideation, and difficulty in establishing and maintaining effective relationships, are contemplated in his current 50 percent rating. As noted previously, a 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. In the instant case, the Board finds that the Veteran's PTSD symptomatology does not more nearly approximate occupational and social impairment with deficiencies in most areas. In this regard, the record is devoid of evidence suggestive of obsessional rituals interfering with routine activities. See May 2014 VA examination report; August 2016 DBQ examination report. While the Veteran's speech was found to be "slow" by the August 2016 DBQ examiner and "rambling, a bit circumstantial" by the March 2016 VA psychologist, such symptoms are contemplated in his current 50 percent rating, and speech was otherwise found to be normal or "well-spoken" in various clinical records. See October 25, 2013 VA treatment note; May 2015 VA treatment note; January 2016 VA treatment note; February 25, 2016 VA treatment note; July 19, 2016 VA treatment note. Further, the clinical evidence consistently reflects that the Veteran was alert and oriented as to time, place, and person. With regard to suicidal ideation, the Veteran stated that he had received treatment for "suicidal thoughts" in his June 2015 substantive appeal, and the August 2016 DBQ examiner noted that the Veteran had "admitted to sporadic, short lived SI/HI." However, the August 2016 DBQ examiner noted that the Veteran denied "formulation of plan, intent or any attempts" and current suicidal ideation. Furthermore, the Veteran consistently denied suicidal ideations during the entire appeal period. See April 1, 2013 VA treatment note; May 28, 2013 VA Social Work treatment note; June 2013 VA Social Work treatment note; August 2013 VA treatment note; October 2013 VA treatment note; May 2014 VA examination report; May 2015 VA Social Work treatment note; May 2015 VA treatment note; December 2015 VA treatment note; January 2016 VA treatment note; February 2016 VA treatment notes; March 2016 VA treatment note; May 2016 VA Social Work treatment note; July 19, 2016 VA treatment note. Moreover, there is no indication that suicidal ideation, if any, results in occupational and social impairment with deficiencies in most areas. Additionally, there is no evidence that the Veteran suffers from impaired impulse control or symptoms of similar severity. While the Veteran's sister wrote that his temper was "very short and explosive" in the March 2014 correspondence, and the May 2014 VA examiner observed "easy arousability to irritation," the record is negative for physical assaults or violence during the entire appeal period. In this regard, the Veteran's judgment and insight were consistently noted to be intact, and violent ideations were consistently denied in VA treatment records. See October 2013 VA treatment note; May 2015 VA treatment note; December 2015 VA treatment note; July 19, 2016 VA treatment note. Furthermore, the evidence fails to demonstrate that the Veteran neglects his personal appearance and hygiene. In this regard, VA treatment records and examination reports consistently show that he was well-groomed. In fact, the Veteran was described as "wearing extremely expensive knee high laced, European made black leather boots" in the February 25, 2016 VA treatment record. The evidence also fails to demonstrate near-continuous panic, depression, or any symptoms of similar severity affecting the Veteran's ability to function independently, appropriately, and effectively. While the Veteran has reported depression and anxiety, he indicated that such were due to various physical ailments, to include his urinary incontinence problems. See May 2014 VA examination report; February 25, 2016 VA Social Work treatment note; July 19, 2016 VA treatment note. Furthermore, such reported depression and anxiety symptoms are not shown to be near-continuous, as the Veteran has often exhibited euthymic mood and hopeful outlook on his future. See October 25, 2013 VA treatment note (observing that the Veteran was "generally euthymic, animated, playful"); May 2014 VA examination report (noting that the Veteran "generally was forward looking and had distinct plans for the future" and that "he does not feel useless, helpless, or hopeless and his self-esteem seems relatively intact."); February 25, 2016 VA treatment note (noting the Veteran's report that he was "hopeful" about future romantic prospects); August 2016 DBQ examination report (noting that the Veteran denied feelings of hopelessness). In addition, such have not affected his ability to function independently, appropriately, and effectively, as he consistently maintained appropriate hygiene and was able to perform his activities of daily living, to include shopping, "going out 2 to 3 times per week" with his sister and brother, and periodically taking care of his ill sister and brother-in-law. See May 2014 VA examination report; July 2016 VA treatment note. Furthermore, the evidence fails to demonstrate that the Veteran is unable to maintain and establish relationships, as the record indicates that he maintains functional relationships with his siblings despite his PTSD symptomatology. In this regard, the Board is cognizant of the Veteran's general implication that interacting with his family members does not constitute a social life. However, the question before the Board involves social impairment as opposed to the nature and/or quality of one's social life. On this point, the Board finds that the Veteran's PTSD symptomatology does not result in his inability to establish and maintain effective relationships. Indeed, in the March 2014 correspondence, the Veteran's sister stated that the Veteran and his siblings were "very close" and that they "depend[ed] on each other greatly." At the May 2014 VA examination, the Veteran reported that he was "going out 2 to 3 times per week" and spent time with his siblings "within the restrictions of his physical condition and resources." The March 2016 VA treatment note reflects that the Veteran "had an enjoyable 75th birthday celebration with his sister and brother in law at a steak house . . . ." Furthermore, the August 2016 DBQ examiner found those protective factors included the Veteran's connections to his siblings and religious beliefs. Therefore, the evidence of record indicates that the Veteran is able to maintain functional, effective relationships with his family. The record also shows that the Veteran was able to participate in activities in his community, to include attending church and volunteering at a substance abuse treatment facility, suggestive of his ability to form and maintain functional relationships outside of his family. See May 2014 VA examination report (noting that the Veteran had been attending church); February 25, 2016 VA Social Work treatment note (noting the Veteran's report that "doing volunteer work has been very beneficial for his mental health . . . .). While the Veteran reported "reduction in social activities" including "volunteer/church activities" during the August 2016 examination, he indicated that such was mainly due to his health problems, and that he continued to maintain contact with his brother and sister. Consequently, the Board finds that the Veteran's symptomatology does not result in occupational and social impairment with deficiencies in most areas, as required by a 70 percent rating. With regard to the Veteran's ability to adapt to stressful circumstances, to include work or a worklike setting, the Veteran has indicated that he has been retired since 2000 due to his ankle and back problems. See June 2004 VA Spine examination report; May 2014 VA examination report. The December 2015 VA treatment note indicates that he previously worked as a "salesman," and the record does not show that he has claimed work-related problems as result of his service-connected PTSD in any of his previous positions. In fact, the Veteran identified one of his strengths as "previous job success" in the April 2013 VA treatment note. He also reported that he was able to "read through the AARP magazine and find it interesting and read through the entire thing usually in 1 or 2 sittings," suggesting that he was able to focus his attention and adapt to work-like tasks. See May 2014 VA examination report. In addition, while the Veteran reported during the February 25, 2015 VA Social Work treatment that he experienced "some stress due to health problems," he stated that "doing volunteer work has been very beneficial for his mental health," indicative of his ability to manage and adapt to stressful circumstances. He has also reported that despite his "increased anxiety due to upcoming surgical procedure," he was able to be ". . . confident" and "optimistic" about the stressful situation. See May 2016 Social Work treatment note. Therefore, the Board finds that the Veteran's ability to manage and adapt to stressful circumstances do not result in occupational and social impairment with deficiencies in most areas. The evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating criteria, to include sleep impairment and periodic nightmares. See Mauerhan, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 50 percent under the General Rating Formula as they are not of such severity or frequency to result in occupational and social impairment with deficiencies in most areas or total occupational and social impairment. In this regard, as indicated previously, the Veteran is able to maintain effective, functional relationships with his family and his PTSD has not been shown to interfere with his employability. The Board also finds that the Veteran's PTSD does not more closely approximate the criteria for a 100 percent rating. In this regard, the Veteran's symptoms have not been manifested by 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Again, the Veteran was consistently noted to be well-groomed and oriented as to place, person, and time at the mental status examinations conducted during the appeal period. His speech was noted as normal or well-spoken, and his affect was found to be normal. Furthermore, as noted, the Veteran consistently denied thoughts of suicide or violence, or past attempts of suicide, as well as hallucinations and delusions. Consequently, the Board finds that the Veteran's symptomatology does not result in total occupational and social impairment. The Board has considered whether staged ratings are appropriate for the Veteran's service-connected PTSD. See Fenderson, supra. However, the Board finds that his symptomatology has been stable throughout this appeal period. Therefore, assigning staged ratings for PTSD is not warranted in the instant case. In sum, Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 50 percent for PTSD. Therefore, the benefit of the doubt doctrine is not applicable and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Other Considerations The Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined 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 Court indicated that 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. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which such disability is rated. In this regard, relevant to the Veteran's PTSD claim, the Federal Circuit provided guidance in rating psychiatric disabilities, emphasizing that the list of symptoms under a given rating is nonexhaustive. Vazquez-Claudio, supra. The psychiatric symptoms present in this case are either listed in the schedular criteria or are similar in kind to those listed, as discussed above. Review of the record does not reveal that the Veteran suffers from any symptoms of PTSD that are not contemplated in the nonexhaustive list of symptoms found in the schedular criteria. Furthermore, the rating schedule provides for greater compensation for greater disability than that suffered by the Veteran. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. The Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, as discussed in the preceding sections, all manifestations of such disabilities are considered in the currently assigned disability ratings. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Furthermore, the Veteran has stated that he has had no work-related problems in the past. See July 2014 VA Psychiatric Examination Report. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for total disability rating for compensation based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In the instant case, the record does not show either an express or implied TDIU claim for the relevant period. The record reflects that the Veteran has been retired since 2000 due to problems other than the service-connected PTSD, to specifically include "ankle" and "back" problems. See June 2004 VA Spine examination report; May 2014 VA examination report. The record reflects that the Veteran had been previously employed as a salesman and that he denied any work-related problems. See December 2015 VA treatment note. Overall, there is no evidence that the Veteran's PTSD renders him unemployable. Therefore, a TDIU is not raised in the instant case and, as such, need not be further addressed. ORDER A rating in excess of 50 percent for PTSD is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs