Citation Nr: 1753028 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 13-19 642 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to May 10, 2011. 2. Entitlement to a rating in excess of 50 percent from May 11, 2011 to December 21, 2016. 3. Entitlement to a rating in excess of 70 percent from December 21, 2016. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD D. Barrett, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1952 to April 1954. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York which granted service connection for PTSD and assigned an initial 30 percent rating as of September 24, 2010. In August 2011, the RO granted an increased rating to 50 percent as of May 11, 2011. In January 2017 the RO granted an increased rating to 70 percent as of December 22, 2016. Because these ratings are less than the maximum benefit allowed by law and VA regulations, the claim remains on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). In a February 2014 statement, the Veteran withdrew his previous request for a videoconference hearing. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. Prior to May 11, 2011, the Veteran's PTSD was manifested by symptoms such as anxiety, depression, panic, chronic sleep impairment with nightmares, recurrent distressing thoughts of war, social isolation, and increased irritability, all of which caused no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. From May 17, 2014, the Veteran's PTSD was manifested by symptoms such as chronic sleep impairment, social avoidance, and irritability, depression, anxiety, and difficulty in adapting to stressful circumstances which resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood; total impairment was not shown. CONCLUSIONS OF LAW 1. Prior to May 10, 2011, the criteria for an initial rating in excess of 30 percent for PTSD were not met. 38 U.S.C. §§ 1155, 5107 (2017); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2017). 2. Beginning May 17, 2014, the criteria for a 70 percent rating, and no higher, have been met. 38 U.S.C. §§ 1155, 5107 (2017); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.130, DC 9411 (2017). 3. From December 21, 2016, the criteria for a rating in excess of 70 percent have not been met. 38 U.S.C. §§ 1155, 5107 (2017); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.130, DC 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is a proximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 4.3 (2017). The criteria for evaluating psychiatric disorders (other than eating disorders), to include PTSD, are set forth in a General Rating Formula. See 38 C.F.R. § 4.130. The Veteran has been assigned an initial 50 percent rating for PTSD under DC 9411. He maintains that his disability warrants a higher rating. VA regulations formerly required evaluation of mental disorders using the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). 38 C.F.R. §§ 4.125, 4.126 (2017). Effective March 19, 2015, VA adopted as final, without change, an interim final rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders. The interim final rule replaced outdated references with references to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and updated the nomenclature used to refer to certain mental disorders in accordance with DSM-5. See 79 Fed. Reg. 45093 (August 4, 2014). Specifically, the rulemaking amended 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130. The revised regulations and evaluations performed under the criteria of DSM-5 will apply. However, the Secretary has specifically indicated that all diagnoses completed under the DSM-IV may still be applied for any claims pending before the Board. Id. Therefore, the Board will consider both DSM-IV and DSM-5 diagnoses provided in the Veteran's claims folder in reaching a decision regarding the Veteran's claim for a higher initial rating for PTSD. The General Rating Formula for Mental Disorders (including PTSD) provides for a rating of 30 percent for 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). 38 C.F.R. § 4.130, DC 9411. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased disability rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)(4th ed. 1994); 38 C.F.R. § 4.125. There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. Id.; see also 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). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 is indicative of 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. DSM-IV at 47. When evaluating the level of disability from a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign a disability rating based solely on the basis of social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Service connection for PTSD was granted by a December 2010 rating decision with an evaluation of 30 percent effective September 24, 2010. An August 2011 rating decision granted an increased rating to 50 percent as of May 11, 2011. A January 2017 rating decision granted an increased rating to 70 percent as of December 22, 2016. The Board will discuss each staged rating separately. Period Prior to May 10, 2011 The Board finds a rating in excess of 30 percent is not warranted for the appeal period to May 10, 2011 because the evidence shows the Veteran's PTSD resulted in occupational and social impairment causing no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran was afforded a VA examination in October 2010. He was accompanied to the exam by his wife of nearly 55 years. He reported experiencing nightmares related to his service in Korea during the Korean War. He noted that he had worked for the highway department until he retired in 1993; his hearing problems had affected his work. He then owned a shoe repair shop until 2002. He had not seen a psychiatrist because he tried to handle his problems on his own, nor had he taken any psychotropic medications. He reported that he never attempted suicide, had no thoughts of wanting to harm people, and had no violent outbursts since being out of the war. He had never been in jail or prison nor been on probation. He did not use alcohol or drugs since coming back from the war. The Veteran reported that he enjoyed attending reunions with his original Army division. He reported some sleep impairment related to nightmares. On mental status examination, the examiner found the Veteran had good eye contract, was casually dressed and adequately groomed. He was cooperative and attentive with the examiner as well as alert and oriented in person, place and time. He showed no obvious psychomotor retardation or agitation. His speech was spontaneous and anxious at times when talking about his Korean War combat traumatic experiences. He showed an anxious affect throughout the examination. He showed no delusional features and did not appear to be responding to any internal stimuli such as auditory hallucinations. His thought processes were coherent. His insight appeared to be fair and his judgement was good. The examiner determined the PTSD was of moderate severity, and assigned a GAF score of 45. The examiner opined that the Veteran has had mild interpersonal problems over the years as a result of his PTSD condition, mainly on an intermittent basis. He has had perhaps, moderate occupational problems at times due to lack of sleep as well as hearing problems. He had no suspensions while he was on the job however. In January 2011 the Veteran began individual therapy sessions with a VA social worker. At their first session, the Veteran stated his problems began shortly after he retired in 1993. He noticed he had more time on his hands and began to feel more depressed and irritable. He complained of low frustration tolerance, a "sarcastic" attitude with wife, and becoming more argumentative. He also reported becoming more emotional and tearful when he viewed pictures of others in pain or hurting. He reported reflecting back on his military experiences and feeling "lucky" to have lived what he went through. He described experiencing intrusive, distressing thoughts and images that recalled traumatic events from his combat tour and the associated intense emotional responses. He noted that coverage of current U.S. conflicts in Iraq and Afghanistan would trigger intense distress when he was exposed to it on television (e.g. he would start crying and feel irritable). He described incidents of becoming angry and losing his temper more easily, especially when he reflected on previous denials by the VA for his tinnitus. He reported a sad affect, lack of energy, and social withdrawal. The Veteran also began seeing a VA psychiatrist in April 2011. In April and May 2011 the Veteran reported his mood was fine most of the time but at times felt depressed. He denied any period of depression for two weeks or longer. He reported sleep impairment, including nightmares. His appetite was better but he gave a history of poor appetite and losing weight. He denied any problem with concentration or attention span and stated his memory was good. He denied any period of hopeless and worthlessness. He denied any suicidal or homicidal ideations, thoughts, or plan. He had no past history of suicide attempts and denied any history of family members who attempted or committed suicide. He reported that he thought about the war experience and about his buddies a lot and which bothered him. He reported that his temperament was good and it took a lot to make him angry, but also reported mood swings off and on. He reported that he was a suspicious person, but denied any auditory or visual hallucinations. Based on a review of the evidence and the Veteran's history during this period, the Board finds that since the grant of service connection, the Veteran's PTSD manifested with symptoms that more closely approximate the criteria for a 30 percent rating. That is, his symptoms have resulted in no worse than mild to moderate occupational and social impairment. See 38 C.F.R. §§ 4.1, 4.130 (DC 9411); see Fenderson, 12 Vet. App. at 126. The Veteran's PTSD resulted in symptoms that include, but are not limited to depression, nightmares, intermittent mood swings, and some social withdrawal. The Veteran is competent to report his experiences and symptoms and his statements have been considered by the VA primary care clinicians and VA examiners. These symptoms are similar to many of those contemplated by the currently assigned 30 percent rating. In particular, the General Rating Formula lists, inter alia, depressed mood, suspiciousness, and chronic sleep impairment among the types of symptoms associated with a 30 percent rating. 38 C.F.R. § 4.130. Although the 50 percent rating criteria also contemplate disturbances of motivation and mood, the Veteran's frequency of mood disturbance and depression is more closely analogous to that contemplated by his current 30 percent rating. Specifically, the Veteran only reported occasional mood swings. He also reported a good temperament and that it took a lot to make him angry. The Veteran was able to maintain productive and meaningful relationships with his wife and family. In fact, he has maintained his marriage for over 50 years. At the 2010 VA examination, he also reported that he enjoyed socializing with former service members. Further, the evidence does not show that when he was working, his PTSD resulted in any significant impairment. He also denied any disciplinary actions in his 23 years at the highway department; or in the many years at the shoe repair shop. The evidence is not supportive of an initial rating in excess of 30 percent prior to May 10, 2011 based on the cumulative nature, frequency, and severity of the Veteran's PTSD symptoms during that period. Period Beginning May 11, 2011 The Veteran's PTSD is currently rated at 50 percent beginning May 11, 2011, until December 21, 2016. Based on a review of the evidence during this period, the Board finds that the Veteran's PTSD has manifested with symptoms that more closely approximate the criteria for a 70 percent rating - but only beginning from May 17, 2014. Prior to May 17, 2014; the current 50 percent rating is appropriate. The Veteran was afforded a VA examination in July 2011. He reported a good relationship with his wife of 56 years and the rest of his family. He noted that he had always been close to his wife. He reported that his social relationships were limited - he played cards with friends and use to go out more, but now he did not feel like it as much anymore. He had been resistant to go fishing with a friend and no longer played golf after losing fingers in a table saw. His leisure pursuits included spending time with his family, doing things with his wife, and playing cards. He reported continued sleep impairment and that he and his wife slept in separate beds because of his thrashing. His wife reported that she woke up to the Veteran screaming in his sleep. He denied suicidal attempts and a history of violence. The Veteran reported that he stopped working because he was eligible by age or duration of work. On mental status examination, the examiner found the Veteran clean and neatly groomed. His speech was spontaneous and his psychomotor activity was unremarkable. He was cooperative with the examiner. His affect was constricted and he cried when he talked about something that he had to do that he was reluctant to do. His mood was sometimes dysphoric. He was oriented in person, time, and place. His thought process was rambling but this thought content was unremarkable. He did not have delusions or hallucinations. He presented average intelligence and understood the outcome of his behavior. Inappropriate behavior was noted, such as arguing with his wife more than he should. He denied panic attacks and homicidal or suicidal thoughts. No violence was noted. The examiner noted obsessive/ritualistic behavior demonstrated by the Veteran's reported a need for cleanliness and order. The examiner did not expand upon the effect of this behavior on the Veteran's occupational and social functioning. However, the examiner noted that the only problem the Veteran had with activities of daily living was a slight effect on his ability to shop. He reported some difficulty concentrating. The examiner assigned a GAF score of 50. The examiner noted that this score was rendered based upon the Veteran's current functioning with impairments in social and intrapsychic functioning. The examiner further explained that during his last examination for PTSD he was rendered a GAF score of 45, but it was likely due to the Veteran's other health impairments, not just his PTSD. The examiner also assessed the Veteran's overall level of social and occupational impairment due to PTSD symptoms was best characterized as reduced reliability and productivity. The Veteran was afforded another VA examination in September 2012. He reported the relationship with his wife of now 56 years was good. However, he reported emotional distancing had occurred, especially regarding the trauma he experienced while he was in the military. He reported a good relationship with his three children and his siblings. He reported that he had many close friends in the past, but had recently decreased interest in contact with them. He did not leave the house as frequently as before and that has led to a decrease in contact with others. He reported many symptoms of depression, such as crying spells, sleep disturbances, low energy/fatigue at times, difficulty concentrating, and occasional feelings of hopelessness. He also experienced nightmares. On mental status examination, the following symptoms were noted: depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and survivors' guilt. The Veteran had persistent symptoms of increased arousal as indicated by difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and an exaggerated startle response. Regarding the Veteran's social impairment, the examiner described it as mild. Regarding occupational impairment, the examiner estimated the Veteran would experience at least a moderate level of occupational impairment due to moderate symptoms of PTSD if he were to return to work. He assigned a GAF score of 48. The examiner provided diagnoses of PTSD, dysthymic disorder and generalized anxiety disorder but determined that it is not possible to differentiate what symptoms are attributable to each diagnosis. The examiner stated that the Veteran's level of occupational and social impairment with regards to all mental diagnoses was best summarized as occupational and social impairment with reduced reliability and productivity. VA treatment records dated between 2011 and 2014 show that the Veteran was generally functioning well. In February 2012, the Veteran reported that his mood was "fine." He denied symptoms of depression, anxiety, nightmares, flashbacks or other signs of hypervigilance. He also denied having a lack of motivation and reported that he tried to keep himself busy. He enjoyed going out with friends and with his wife to the casino at least once a month. In November 2013, however, he reported poor sleep (racing thoughts), intrusive thoughts (vivid memories from Korea). He also endorsed some short-term memory/concentration problems, irritability, and noted that he was argumentative at times. When seen in March 2014, the Veteran reported that he was generally a social person, but that he had reduced his social connections to be more available to his wife who is also suffering from a psychiatric disorder. He noted that he played cards with several friends once or twice a month when he is able. Multiple mental status examinations revealed that he was fully oriented, had normal speech, appropriate affect and euthymic mood. His judgment and insight was 'fair' to 'ok'; and his thought process and content remained intact and devoid of any delusion or obsessions. Also no suicidal attempts or thoughts, auditory or visual hallucination or paranoid ideations were noted. The Veteran continued VA therapy sessions through October 2015. He consistently presented with a depressed mood. He was conversant, cooperative, and oriented in person, place, and time. His speech was consistently normal in rate and tone. He consistently presented an appropriate affect, intact thought process, and fair judgment and insight. No auditory or visual hallucinations or paranoid ideations were noted. No past history of suicidal attempts was reported. The treatment records show that during this period, the Veteran fought a local ordinance so he could have chickens on his property. He expressed concern that he was so involved in this hobby and was able to spend a good amount of times "taking care of his birds." At one point he went door-to-door gathered 30 signatures from surrounding neighbors to request an exception to the city ordinance. Another significant event was when the Veteran traveled to Washington, D.C., to attend the anniversary of the Korean War armistice. He was pleased to see how welcoming the citizens of Washington were to the visiting veterans. He attended the ceremony and listened to former President Obama and other speakers. The Veteran was afforded another VA examination in May 2014. He reported that his relationship with his wife of 59 years was excellent, as was his relationship with his three sons. He reported that he still had a lot of friends but does not engage with them in organized social activities and generally stayed home. He stated that he had no hobbies or leisure pursuits but enjoyed his grandchildren and great grandchildren. On mental status examination, the examiner found the Veteran suffered from symptoms such as depressed mood, anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks, and difficulty in establishing and maintaining effective work and social relationship. He also experienced crying spells, loss of usual interests, and a diminished sense of pleasure. The examiner noted that along with his low mood this represented a depressive episode with a stable intensity. The examiner concluded that the Veteran suffered occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Based on a review of the evidence, the Board finds that the Veteran's PTSD has manifested with symptoms that more closely approximate the criteria for a 70 percent rating beginning from May 17, 2014. The examiner at the May 17, 2014 VA examination determined that the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas. This is consistent with a 70 percent rating. Prior to the May 2014 examination, however, the evidence reflects that the Veteran's psychiatric symptoms resulted in no worse than moderate to severe occupational and social impairment- consistent with a 50 percent rating. For this reason, a rating in excess of 50 percent prior to May 17, 2014 is not warranted. Prior to May 2014 the Veteran's PTSD symptoms primarily included sleep impairment, difficulty concentrating, depression, some social isolation and loss of interest in significant activities, and mildly impaired memory. These symptoms are similar to many of those contemplated by the currently assigned 50 percent rating. The General Rating Formula lists impairment of short- and long-term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships among the types of symptoms associated with a 50 percent rating. 38 C.F.R. § 4.130. The 70 percent rating criteria also contemplate some of the other symptoms the Veteran is noted to have experienced- such as difficulty in adapting to stressful circumstances, obsessional rituals, and unprovoked irritability. However, the evidence does not show that any of these particular symptoms resulted in severely impaired functioning. All of the VA examiners and clinicians during this period, who interviewed and evaluated the Veteran, determined that his psychiatric disorder was of moderate severity. The cumulative clinical findings, and the lay testimony of the Veteran, fail to show that any of these symptoms manifested with such frequency and severity so as to have resulted in severe impairment socially or occupationally. Further, the Veteran was not unable to establish and maintain effective relationships. While he reported lost interest in some social activities, he maintained that his relationship with his family is excellent and he loves spending time with his grandchildren and great grandchildren. He was also able to travel to the nation's capital for a veterans' event and visit the casino at least once a month. He was also able to interact appropriately with at least 30 of his neighbors in his fight against a local ordinance. While the Veteran has also reported some irritability, such as arguing with his wife; he has not had any violent outbursts or history of physical violence. Also despite occasional mood swings, he has not been violent. The Veteran has also consistently denied suicidal ideations. He has not been noted to have spatial disorientation, neglect of personal appearance and hygiene, or illogical, obscure, or irrelevant speech upon clinical observation. The Board is mindful that the Veteran was assigned a range of GAF scores, including a 45 by the October 2010 VA examiner, a 50 by the July 2011 examiner, and a 49 by the September 2012 VA examiner that are indicative of 'serious symptoms.' However, GAF scores alone are not determinative of the rating assigned by VA in evaluating a psychiatric disorder under the rating criteria. Considering the Veteran's overall disability picture, and the medical professionals' opinions, no more than moderate impairment is shown prior to May 17, 2014. For these reasons, a rating in excess of 50 percent is not warranted prior to May 17, 2014. A rating of 70 percent, but not higher is warranted thereafter. In finding that a rating in excess of 70 percent is not warranted for any period after May 17, 2014, the Board first notes that the May 2014 VA examiner opined that the Veteran did not have total impairment due to his PTSD symptoms. In addition, the Veteran was afforded a VA examination in January 2017. He continued to describe his relationship with his wife as excellent, while his wife clarified that they had their "trials and tribulations" and she would describe their relationship as good. The Veteran still felt his relationship with his kids was excellent, but he remained socially disengaged. His wife seemed to imply that his lack of a social life and a lack of hobbies and leisure pursuits likely contribute to the arguments they had. The Veteran had not been hospitalized for mental health reasons nor had he been engaged in outpatient mental healthcare since December 2015. He indicated interest in mental healthcare but stated that the clinic stopped scheduling him with appointments. On mental status examination, the examiner found the Veteran suffered from symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, difficulty in understanding complex commands, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. He also experienced crying spells, guilt, hopelessness, loss of usual interests, and a low self-esteem. In addition, marked alterations in arousal and reactivity experienced was evidenced by irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. The examiner concluded that the Veteran did not experience total occupational and social impairment, but rather impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran has not experienced the type of symptoms contemplated by the 100 percent rating criteria for total occupational and social impairment, such 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, disorientation to time or place, and memory loss for names of close relatives or own name. The Veteran has always had clear and coherent thought processes at examinations. He has consistently been conversant and cooperative. He has always denied delusions and hallucinations. He has never exemplified grossly inappropriate behavior, nor has he ever reported any suicidal or homicidal ideations. The 2014 and 2017 VA examiners have concluded he has occupational and social impairment in most areas, but total impairment has never been established. A rating in excess of 70 percent from May 17, 2014 is not warranted as total social and occupational impairment due to service-connected PTSD has not been shown. See 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). There are no additional expressly or reasonably raised issues presented on the record. ORDER Prior to May 10, 2011, an initial evaluation in excess of 30 percent for PTSD is denied. Beginning May 17, 2014, a 70 percent rating, and no higher, for PTSD is granted. A rating in excess of 70 percent from December 21, 2016 is denied. ____________________________________________ D. JOHNSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs