Citation Nr: 1804436 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 12-24 145 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an increased evaluation, in excess of 50 percent, for post-traumatic stress disorder ("PTSD"). REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Timbers, Associate Counsel INTRODUCTION The Veteran served as a member of the United States Army, with active duty service from March 1970 through September 1971. This appeal comes to the Board of Veterans' Appeals ("Board") from a March 2011 rating decision by the Department of Veterans Affairs ("VA") Regional Office ("RO") in Houston, Texas (hereinafter Agency of Original Jurisdiction ("AOJ")). In pertinent part, the March 2011 rating decision granted the Veteran entitlement to service connection for PTSD, and assigned a 50 percent disability evaluation effective March 17, 2009. In April 2017, the Veteran testified before the undersigned Veterans Law Judge, via a video conference hearing. A transcript of this hearing has been reviewed and associated with the claims file. The Veteran's claim was previously before the Board. In August 2017, the Board remanded the Veteran's claim to the AOJ for further development. Specifically, the Board directed the AOJ to obtain the Veteran's updated VA treatment records and to provide him with a VA examination. A review of the claims file indicates that the requested development has been completed and that the appeal has been properly returned to the Board. See Stegall v. West, 11 Vet. App. 268 (1998). In statements to the Board, the Veteran has alleged that the symptoms of his PTSD impair his ability to maintain employment. See e.g. Correspondence Dated March 2011 and July 2011. Where a claimant, or the record, reasonably raises the question of whether the Veteran is unemployable due to the disability for which a higher rating is sought, then part and parcel to that claim for a higher rating is the matter of whether a total rating based on individual unemployability ("TDIU") as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009); see also VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996). However, the Veteran testified that he maintains two online businesses. See Hearing Transcript. As such, Rice is not for application in the instant appeal. This appeal was processed using Virtual VA and the Veterans Benefits Management System ("VBMS"). Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. Beginning on and after March 17, 2009, the Veteran's PTSD symptoms have been manifested by social isolation, constant depression, anxiety, frequent panic attacks, intrusive thoughts, irritability, hypervigilance, increased startle responses, flashbacks, persistent nightmares three to four times per week, insomnia, mild memory loss, difficulty concentrating, loss of interest, and suicidal ideations. 2. Beginning on and after March 17, 2009, the Veteran's service-connected PTSD symptoms more nearly approximated a disability picture manifest by psychiatric symptoms causing occupational and social impairment, with deficiencies in most areas. However, there has been no evidence suggesting that the Veteran's service-connected PTSD symptoms caused total social and occupational impairment at any time during the period on appeal CONCLUSION OF LAW The Veteran's service-connected PTSD meets the requirements for an initial increased evaluation of 70 percent, but no higher, for the period beginning on and after March 17, 2009. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act ("VCAA") must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his or her claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2017). The Veteran's claim for an increased initial rating of his PTSD disability is considered a "downstream" element of the AOJ's grant of service connection. For such downstream issues, notice under 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159 is not required in cases where such notice was afforded for the originating issue of service connection. See VAOPGCPREC 8-2003 (Dec. 22, 2003). Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In correspondence dated March 2009, VA notified the Veteran of the information and evidence needed to substantiate and complete his claim for service connection for PTSD, including what part of the evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 6 Vet. App. 183, 187 (2002). The Board is aware of the decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) in which the Court held that, for an increased-compensation claim, section § 5103(a) requires, at a minimum, VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Relying on the informal guidance from VA's Office of General Counsel ("OGC") and a VA Fast Letter issued in June 2008 (Fast Letter 08-16; June 2, 2008), the Board finds that Vazquez-Flores is not applicable. According to OGC, because this appeal arises from an initial rating decision, VCAA notice obligations are satisfied fully once service connection has been granted. Any further notice and assistance requirements are covered by 38 U.S.C. §§ 5104(a), 7105(d)(1), and 5103A as part of the appeals process, upon the filing of a timely notice of disagreement ("NOD") with respect to the initial rating or effective date assigned following the grant of service connection. In Dingess v. Nicholson, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91 (2006). To the extent that Dingess requires more extensive notice as to potential downstream issues such as disability rating and effective date, because the currently appealed rating decision was fully favorable to the Veteran on the issue of service connection for PTSD, and because the Veteran was fully informed of the evidence needed to substantiate this claim, the Board finds no prejudice to the Veteran in proceeding with the present decision. See also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). With respect to the timing of the notice, the Board points out that the Court has held that a VCAA notice, as required by 38 U.S.C. § 5103(a), must be provided to a Veteran before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini, 18 Vet. App. at 112. Here, all relevant notice was issued prior to the currently appealed rating decisions; thus, this notice was timely. And any defect in the timing or content of the notice provided to the Veteran and his service representative has not affected the fairness of the adjudication. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the Board. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. This includes records identified by the Board in the August 2017 remand order. A review of the file indicates that the requested updated VA treatment record have been obtained and properly associated with the Veteran's claims file. See Stegall, 11 Vet. App. 268 at 271. The Veteran has been provided with multiple VA examinations which addressed the Veteran's reported symptoms, frequency, and severity and the interference these symptoms cause in his ability to complete basic daily tasks. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Most recently, the Veteran was provided with a VA examination and medical opinion in August 2017, as requested by the Board's prior remand. See Stegall, 11 Vet. App. 268 at 271. During this August 2017 VA examination, the pertinent medical history was noted by the examiner and the examiner's findings were set forth in detail, allowing for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examination of record are adequate for rating purposes and an additional examination is not necessary regarding the claim adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. The Veteran was afforded the opportunity to appear and testify before the undersigned Veterans Law Judge ("VLJ") via video conference hearing in August 2017. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge ("VLJ") who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the basis of the prior determination and noted the element of the claims that was lacking to substantiate the claims for benefits. The VLJ specifically noted the issues as including the issues listed on the title page of this decision. The Veteran was assisted at the hearing by an accredited representative from the Texas Veteran Commission. The representative and the VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of these claims. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that any error in notice provided during the Veteran's hearing constitutes harmless error. Based upon the above, the Board finds that VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Moreover, the neither the Veteran nor his representative have advanced any procedural arguments in relation to VA's duties to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances . . . we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran . . ."). Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Lastly, the Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Governing Laws and Regulations for Increased Ratings Claims: Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities ("Rating Schedule"), found in 38 C.F.R. § 4.1 (2017). 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. Separate diagnostic codes identify the various disabilities and each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition. 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. § 1155; 38 C.F.R. § 4.10. As such, each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, the relevant time period for consideration begins on the date that the claim for service connection was filed. Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). In the instant appeal, that date is March 17, 2009. Moreover, the Board acknowledges that a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that in analyzing this claim, the Secretary, and therefore the Board, has an obligation to provide the Veteran with the "benefit of the doubt" on questions material to this decisions, for which there is an approximate balance of positive and negative evidence. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). When evaluating a service-connected mental disorder, VA will review the Veteran's medical history to determine how badly the disorder has disrupted his social and occupational functioning. Specifically, VA must review the frequency, severity, and duration of the psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The evaluation must be 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. 38 C.F.R. § 4.126(a). While the extent of a Veteran's social impairment is considered, the rating cannot be assigned on these limitations alone. 38 C.F.R. § 4.126(b). The level of disability is then rated according to a General Rating Formula for Mental Disorders, codified at 38 C.F.R. § 4.130 ("General Rating Formula"), which provides for ratings of zero, 10, 30, 50, 70, or 100 percent. The VA compensates Veterans beginning at 10 percent disability, and compensation increases at each level. In the instant appeal, the AOJ granted service connection for PTSD and assigned disability ratings under Diagnostic Code 9411. Under this Diagnostic Code, a 50 percent rating is assigned 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation 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; intermittently illogical, obscure, or irrelevant speech; 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 inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assignable where 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Evaluation under this formula is "symptom driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). 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. The Board notes that the Veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). 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." Id. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Id. 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. Specifically, the rulemaking amended 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130. However, the provisions of this final rule do not apply to claims that were certified to the Board on or before August 4, 2014, even if such claims are subsequently remanded to the agency of original jurisdiction. As this appeal was certified to the Board in September 2016, the current versions of the regulations including references to DSM-5 apply. In addition to evidence regarding the Veteran's symptomatology and its impact on his social and occupational functioning, a Global Assessment of Functioning ("GAF") score is another component considered to determine the entire disability picture for the Veteran. The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS at 32 (4th ed. 1994)). Higher GAF scores denote increased overall functioning of the individual. For example, a GAF score of 51 to 60 represents "[m]oderate 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)." DSM-IV at 46-47. Lower scores are indicative of greater symptoms and decreasing functionality of the individual. Specifically, a GAF score of 41 to 50 illustrates "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting); or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. While an examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, it 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. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. That being the relevant law applicable to the Veteran's claim for an increased rating of his PTSD, the Board finds evidence of record is consistent with the assignment of an initial 70 percent evaluation for the Veteran's PTSD, effective March 17, 2009. Beginning on and after March 17, 2009, the Veteran's service-connected PTSD is manifested by psychiatric symptoms more nearly approximating occupational and social impairment with deficiencies in most areas, which is required for a 70 percent rating. See 38 C.F.R. § 4.130. The Board has also considered additional, similar symptomatology not specifically addressed in the 70 percent criteria, but causing the appropriate level of occupational and social impairment for a 70 percent rating, under the General Rating Formula. Mauerhan, 16 Vet. App. at 442. In making this determination, the Board has reviewed both the medical and lay evidence of record: the Veteran's lay statements, arguments from his representative, and VA psychological examination dated in January 2011 and August 2017. In reaching this determination, the Board finds that the Veteran's overall PTSD symptoms more nearly approximate a 70 percent disability evaluation beginning on and after March 17, 2009. The medical and lay evidence of record document these symptoms to include social isolation, constant depression, anxiety, frequent panic attacks, intrusive thoughts, irritability, hypervigilance, increased startle responses, flashbacks, persistent nightmares three to four times per week, insomnia, mild memory loss, difficulty concentrating, loss of interest, and suicidal ideations. VA treatment records and VA examinations essentially document that the Veteran's signs and symptoms have remained essentially unchanged since his initial grant of entitlement to service connection on March 17, 2009. These consistent and chronic reports of symptoms provide support for the assignment of an initial evaluation of 70 percent. Significantly, the Board finds that the evidence of record demonstrates that the Veteran's PTSD symptoms have remained consistent, and unchanged, despite medication and counseling. During his initial counseling sessions, the Veteran endorsed nearly daily panic attacks, persistent nightmares, and repeated intrusive thoughts from his service in Vietnam. See Conroe CBOC Records, dated August 2010. The examining clinician observed that the Veteran was cooperative, but displayed a depressed and anxious demeanor. Following this evaluation, the Veteran's medications were increased; however, subsequent encounters show little to no effect on the Veteran's overall level of functioning. For example, during an examination in June 2011, the clinician reported the Veteran's PTSD remained unchanged, with the Veteran experiencing daily panic attacks, and persistent symptoms. The examining clinician additionally observed that the Veteran appeared to be "more irate" despite the prior increases to his medications. This pattern of "persistent" and "chronic" symptoms is continued throughout subsequent evaluations of the Veteran. For example, during a counseling session in August 2011, the Veteran reported daily intrusive thoughts/memories from Vietnam. See Conroe CBOC Records. He reported that he tries to keep himself busy in order to avoid these memories, but is unable to control them. The Veteran additionally endorsed daily panic attacks, described as sweating, rapid heart rate, feelings of dizziness, and faintness. In February 2013, the Veteran continued to report nearly daily panic attacks and described his level of anxiety as "out of control." During this encounter, the Veteran stated that he is "irritated" by people in general, and "cannot stand to be touched" due to his exaggerated startle response and persistent hypervigilance. The examining clinician observed that the Veteran was "tearful" throughout the encounter while he discussed his symptoms of PTSD. See also Conroe CBOC Records, dated February 2015 where Veteran is described as "sad and anxious" throughout evaluation. In addition to the Veteran's chronic anxiety and panic attacks, the medical and lay evidence of record demonstrate significant social impairment due to symptoms of depression and isolation. The Veteran's wife submitted a letter on his behalf, in which she described the Veteran's tendency to isolate from others and to avoid interacting with family. See September 2010 Correspondence from A.H. These lay descriptions of the Veteran are corroborated by statements made during counseling sessions. For example, during his January 2011 VA examination, the Veteran reported feelings of social isolation and withdrawal and stated he experiences persistent feels of worthlessness and does not wish to interact with anyone on a regular or sustained basis. Similar reports were made during the Veteran's August 2017 VA examination. The Veteran's anxiety, intrusive thoughts, and hypervigilance additionally cause him to experience impaired sleep. Throughout the period on appeal, the Veteran has consistently reported nightmares occurring on average three to four times per night. See Conroe CBOC Records. As a result, the Veteran reported that he is able to sleep no more than four to five hours per night, which causes him to experience increased symptoms of irritability and anxiety during the day. The frequency of his nightmares has not improved with either counseling or medication. Rather, in recent statements to the Board, the Veteran reports his nightmares have worsened such that he is no longer able to sleep in the same room as his wife. See December 2017 Correspondence. The Board has additionally reviewed and considered the GAF scores assigned to the Veteran during the pendency of his appeal. Notably, the Board observes that the Veteran's GAF scores have remained more or less unchanged since his initial diagnosis, thus suggesting the persistent and chronic nature of his symptoms. For example, during an August 2010 examination, the Veteran's overall level of functioning was assigned a GAF of 53, which is indicative of moderate symptoms. Thereafter, during a February 2013 examination, the Veteran was assigned a GAF score of 50, which is indicative of serious symptoms. Subsequent evaluations of the Veteran reflect GAF scores between 50 and 55. The Board finds these GAF scores to be consistent with the assignment of an initial 70 percent evaluation, as they indicate the Veteran experiences chronic difficulties in his social functioning and due to daily symptoms of anxiety, hypervigilance, and depression. The Board is aware that the two VA examinations of record, dated January 2011 and August 2017, contain medical opinions which suggest the Veteran's overall level of functioning is consistent with a continued 50 percent disability evaluation. While the Board has considered these opinions, the Board finds that the longitudinal evidence of record is more consistent with the assignment of an initial 70 percent disability evaluation. As explained in greater detail above, the medical and lay evidence of record document persistent and daily symptoms which impair the Veteran's ability to maintain social relationships and perform daily chores/activities. However, while totality of the evidence shows the Veteran's symptoms are consistent with an initial 70 percent disability rating throughout the entire appeal period, the Board finds no credible evidence which would suggest the Veteran's symptoms meet the criteria for a higher evaluation. The medical and lay evidence beginning on and after March 17, 2009, are not indicative of someone with psychiatric symptomatology causing total occupational and social impairment, which is required for the 100 percent rating. 38 C.F.R. § 4.130. Specifically, there is no evidence which documents a gross impairment in thought process or communication; there is no evidence of any delusions or hallucinations; no grossly inappropriate behavior; no "persistent" danger of hurting himself; no disorientation to time or place; and no memory loss for names of close relatives, own occupation, or own name. Id. General observations of the Veteran throughout the period on appeal do not suggest he ever struggled to maintain or neglected his personal hygiene. Rather, he was consistently observed to be appropriately dressed and "neatly groomed." For example, during the January 2011 VA examination, the Veteran was described as "neatly groomed." Similar observations were made during the Veteran's August 2017 VA examination. Furthermore, throughout the period on appeal, the Veteran was able to independently care for himself and his personal hygiene. Most significantly, the overall medical record does not show any periods of in-patient psychiatric hospitalizations or loss of functioning. Rather, the Veteran is treated on an out-patient basis and treated with medications. The totality of these individual therapy reports show the Veteran continued to experience social limitations due to his anxiety, hyperarousal, and mood liability. However, despite these limitations, the totality of the evidence is not suggestive of total social impairment. In sum, the Board finds no medical or lay evidence which shows the Veteran's symptoms resulted in total social impairment. From an occupational standpoint, the Board finds no evidence which suggests the Veteran's symptoms result in a total impairment. For example, during his January 2011 VA examination, the Veteran reported that he had worked for 26 years with AT&T, as a customer service technician, and retired less than a year prior to the examination. This report is significant, because it shows the Veteran was capable of interacting with others on a sustained basis while employed as customer service technician. Since his retirement, the Veteran has been able to engage in a range of daily chores including tending to his family property, planting and harvesting fruit trees, and caring for his family's animals. See e.g. Conroe CBOC Records, dated February 2013, and July 2015, July 2017. The Veteran additionally testified that he currently has two online businesses. See Hearing Transcript. Thus, while the Board acknowledges the Veteran experiences deficits within his social functioning, as described above and as reflected in the assignment of a 70 percent evaluation, his symptoms do result in the level of occupation impairment contemplated by a 100 percent disability evaluation. Similarly, while the Veteran endorses avoidance of certain activities and locations, the overall evidence does not suggest his PTSD precludes him from performing regular daily activities and chores. During his August 2017 hearing, the Veteran testified that he is able to raise catfish on his farm, and additionally sells the fish online as a business. See Hearing Transcript. At no time during the period on appeal has there Veteran reported or alleged any difficulties in his ability to complete daily tasks and chores around the house. The Board has additionally considered whether the Veteran's service-connected PTSD symptoms warrant the assignment of an extraschedular evaluation. 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. 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. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the 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 claimant's disability picture requires the assignment of an extra-schedular rating. Id. 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. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected PTSD. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Accordingly, the Board finds that the evidence supports an initial disability rating of 70 percent, but no higher, for the service-connected PTSD throughout the entire appeal period. 38 C.F.R. § 4.3. It is not necessary to "stage" the Veteran's ratings any further than discussed above, as the Veteran's PTSD symptoms have been consistent at the 70 percent levels for the respective time period delineated by the Board in the present decision. Fenderson, 12 Vet. App. at 126. Therefore, from March 17, 2009 to the present, the Board concludes the evidence supports an initial 70 percent rating, but no higher, for the Veteran's service-connected PTSD. 38 C.F.R. § 4.3. ORDER Subject to the laws and regulations governing the payment of VA compensation, entitlement to an increased initial rating of 70 percent, but no greater, for the Veteran's service-connected PTSD is granted for the period beginning on and after March 17, 2009. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs