Citation Nr: 1420753 Decision Date: 05/08/14 Archive Date: 05/21/14 DOCKET NO. 11-02 974A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to an initial rating greater than 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Kentucky Department of Veterans Affairs ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from June to August 1979 and from January 1986 to July 1992. He also had additional unverified U.S. Army Reserve (USAR) service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which granted the Veteran's claim of service connection for PTSD, assigning a zero percent rating effective November 25, 2008. The Veteran disagreed with this decision in August 2010. He perfected a timely appeal in February 2011. Although the Veteran, through his service representative, requested a Travel Board hearing in October 2012, he subsequently withdrew this request in March 2013. See 38 C.F.R. § 20.704 (2013). In a January 2011 rating decision, the RO assigned a higher initial 30 percent rating effective November 25, 2008, for the Veteran's service-connected PTSD. Because the initial rating assigned to the Veteran's service-connected PTSD is not the maximum rating available for this disability, this claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). FINDING OF FACT The Veteran's service-connected PTSD is manifested by, at worst, complaints of nightmares, panic attacks, and sleep disturbance which are mildly disabling. CONCLUSION OF LAW The criteria for an initial rating greater than 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his 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. The Veteran's higher initial rating claim for PTSD is a "downstream" element of the RO's grant of service connection for this disability in the currently appealed rating decision. For such downstream issues, notice under 38 U.S.C.A. § 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. Hartman v. Nicholson, 483 F.3d. 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In December 2008 and in February 2010, VA notified the Veteran of the information and evidence needed to substantiate and complete the service connection claim for PTSD, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187. 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 RO and the Board although he declined to do so. It appears that all known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file has been reviewed. The RO has attempted to obtain the Veteran's complete Social Security Administration (SSA) records. In response to a request for these records, SSA notified the RO in September 2008 that it had been unable to locate them. The RO formally determined in a February 2010 memorandum that the Veteran's SSA records were not available for review and further attempts to obtain them would be futile. The Board agrees. The Veteran has been provided with VA examinations which address the current nature and severity of his service-connected PTSD. Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claim adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, 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. Higher Initial Rating for PTSD The Veteran contends that his service-connected PTSD is more disabling than currently evaluated. He specifically contends that he is significantly disabled by sleep disturbance and nightmares which he attributes to worsening of his PTSD. Laws and Regulations In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings. The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history. 38 C.F.R. § 4.2; see Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as in this case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected PTSD currently is evaluated as 30 percent disabling effective November 25, 2008, under 38 C.F.R. § 4.130, DC 9411. See 38 C.F.R. § 4.130, DC 9411 (2013). As relevant to this claim, a 30 percent rating is assigned under DC 9411 for PTSD manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned under DC 9411 for PTSD manifested by 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, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned under DC 9411 for PTSD manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood due to such symptoms as suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), or an inability to establish and maintain effective relationships. A 100 percent rating is assigned under DC 9411 for PTSD manifested by total occupational and social impairment due to such symptoms as gross impairment in thought process 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, and memory loss for names of close relatives, own occupation, or own name. Id. The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). As relevant to this claim, a GAF 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, with some meaningful interpersonal relationships. See Carpenter v. Brown, 8 Vet. App. 240, 242- 244 (1995). Factual Background The post-service evidence shows that, in a July 2004 statement, the Veteran asserted that he suffered from PTSD with social phobia. The Veteran's PTSD screen was positive on VA outpatient treatment in July 2007. On VA outpatient treatment in August 2008, the Veteran complained that he woke up "screaming at night" and his wife had to wake him up overnight. He also reported that Paxil and Remeron were "not helping like they used to." The Veteran reported that he slept well and denied any suicidal or homicidal ideation. The assessment included panic/anxiety/depressive disorder with worsening symptoms and PTSD. On VA mental disorders examination in October 2008, the Veteran's complaints included sleep disturbance, a depressed mood "most of the day, nearly every day," and daily insomnia. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran reported that he "currently has a close relationship with his mother. He gets along with his father lately, as he lives down the street from his father and realized that having continued ill will toward his father was doing neither of them any good. His sister lives a few miles south" of him. "He states that he and his sister are not really close but that they do talk 3-4 times a year." His parents were divorced. He had been divorced once and married his current wife in April 2005. He described his current marriage as "a strong marriage." The Veteran was "a social person who likes to be around people." He reported getting only 2-3 hours of sleep per night. "He states that nothing in particular wakes him up, although occasionally he will wake up with his mind quite active." He reported experiencing a recurring nightmare from active service involving a helicopter crash where he was involved in retrieving the personal effects of soldiers who had been killed in the crash. The Veteran had been unemployed since June 2008. Although he previously had abused alcohol, the Veteran had been alcohol free since 1998. Mental status examination of the Veteran in October 2008 showed he ambulated independently, he was clean, neatly groomed, and appropriately dressed, very mild psychomotor retardation, unremarkable speech, intact attention and concentration, full orientation, unremarkable thought processes and content, "no clearly established delusions, however the Veteran admits that when he becomes very depressed he will struggle with issues of suspicion and mistrust," intact judgment, fairly good insight, a reported moderate sleep impairment that "occasionally does interfere with daytime activities," no hallucinations, inappropriate behavior, obsessive or ritualistic behaviors, a history of "both cued and non-cued panic attacks in which his heart pounds, he will sweat, he will have trouble breathing, and feels a sense of doom or that he is having a heart attack" that occurred occasionally, were moderately severe in intensity, and lasted between 30-60 minutes, good impulse control with no episodes of violence, occasional suicidal ideation "which was easily handled and never got to the point of plan," no homicidal ideation, no problems with activities of daily living, normal remote and recent memory, and occasionally mildly impaired immediate memory "because of concentration difficulties associated with his mood disorder." The Axis I diagnoses included recurrent moderate major depressive disorder and panic disorder without agoraphobia. On VA outpatient treatment later in October 2008, it was noted that: [The Veteran] continues to have most of the symptoms of depression, if they are only slightly alleviated, in addition to which he has intrusive memories of having witnessed a helicopter crash and having to deal with some of its aftermath. To some degree it has qualities of flashback and he has nightmares because of it. In addition to that, he has some panic disorder with agoraphobia. The assessment included PTSD. On VA outpatient treatment later in March 2009, the Veteran's complaints included continued nightmares about an in-service helicopter crash "in which there were fatalities," difficulty sleeping, and continued anxiety and panic attacks. The VA clinician stated, "The [Veteran's] condition seems to be approximately the same as when I saw him about 6 months ago. He continues to have symptoms of major depression though he is not suicidal or homicidal, and he denies auditory or visual hallucinations." Objective examination showed no evidence of gross psychosis. The assessment included PTSD. On VA PTSD examination in April 2009, the Veteran complained of PTSD "which he believes is related to his exposure to a helicopter crash while he was in Germany in the military in 1988." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran "has been a welder by trade for much of his adult life post military." He had been married to his current wife for 4 years and had been divorced previously. He had no children. The Veteran reported that his parents' divorce while he was in high school was "the worst thing that ever happened to him as a child or teenager." He cut off his relationship with his father after his parents divorced. His first marriage ended in divorce. He described the in-service helicopter crash that he witnessed in detail. "He indicates that this helicopter accident is the cause of his emotional problems later." The Veteran stopped abusing alcohol in 1998. He had been hospitalized several times since his service separation for depression. "He reports that his relationship with his wife is good and that he has strong, loving feelings towards her and he reports that he feels lots of compassion for people he meets in his day to day life who are having problems of their own." Mental status examination of the Veteran in April 2009 showed "no impairment of thought process or communication," no delusions, hallucinations, "or other active symptoms of psychosis," fair eye contact, no grossly inappropriate behavior, no serious suicidal or homicidal ideation or plan in the previous year, reasonably good hygiene, activities of daily living "curtailed only by the Veteran's problems with his neck and back pain," full orientation, reported memory problems, no obsessive thought patterns or intrusive memories, no compulsive or ritualistic behavior, speech within normal limits with "no grossly irrelevant, illogical, or obscure speech patterns," a reported history of panic attacks "which still occur several times a year," reported symptoms of depression, no "classical signs of impulse control disorders," and reported nightmares and sleep disturbance. The VA examiner stated: The primary stressor the Veteran talks about and really the only stressor is a helicopter crash that occurred when he was in Germany in 1989. If that stressor is verified, then it would appear that the Veteran would meet DSM-4 Stressor Criteria. As far as other symptoms of PTSD, the Veteran is describing re-experiencing symptoms in the form of nightmares, which he says occur multiple times a week. Other than that, the Veteran is not describing many symptoms of PTSD. This VA examiner also stated: I do not believe this Veteran is suffering from posttraumatic stress disorder from any cause...I will state here that I note that the Veteran has really had significant amount of mental health treatment both inpatient and outpatient and no one has given him [a] diagnosis of PTSD that I can find. I think that is actually rather remarkable and the fact that the Veteran could have so much mental health care without people previously noticing that he was suffering from PTSD which is a rather common and well known disorder suggests to me that the Veteran does not suffer from PTSD. The Veteran has had periods of time in his life when his psychosocial functioning and quality of life have not been good, but most of the time these periods of reduced psychosocial function have been related to alcohol dependence and depression and do not appear to be related to PTSD....I do not find anything convincing me that the Veteran has in fact been suffering from posttraumatic stress disorder. The Axis I diagnoses included recurrent major depressive disorder, currently in partial remission, and panic disorder without agoraphobia. On VA outpatient treatment in May 2009, it was noted that the Veteran was being seen with his wife after he had called the suicide hotline and threatened to shoot himself "after receiving a denial letter for service-connected disability benefit increases from the VA." It also was noted that, since March 2009, the Veteran "has remained quite depressed, with middle and terminal insomnia, anhedonia, and decreased libido, with accompanying ongoing erectile dysfunction...He continues to have intrusive memories and nightmares of both seeing a helicopter escort crash in Germany and later recovering the personal effects of the burned passengers and then the passengers themselves." He had a fair appetite. It also was noted that: [The Veteran] reports that he was very angry when he called the hotline and said some things he did not mean, as he reports having no suicidal ideation at the time. He is remorseful that he said the things he said, and said that he has not been experiencing any suicidal ideation, planning, or intent. He says that he would never do such a thing because he loves his wife too much. The Veteran denied any homicidal ideation, auditory or visual hallucinations, or delusions. He lived with his wife. Mental status examination of the Veteran showed he was casually dressed and neatly groomed, with spontaneous speech, linear and logical thought processes without looseness of associations or blocking, "thought content is significant for anger/resentment at VBA," full orientation, fair to poor judgment, and fair insight. The Veteran's Global Assessment of Functioning (GAF) score was 60, indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning. The diagnoses included chronic PTSD. In December 2009, the Veteran reported that "[h]is symptoms returned after he was without his med[ication]s." He had run out of medications while in the Dominican Republic with his ex-wife. Mental status examination of the Veteran showed appropriate dress, normal gait, normal communication and speech, normal motor behavior, full orientation, reported abnormal sleep, reported nightmares, normal thought process, adequate judgment and insight, normal memory. The Veteran's GAF score was 65, indicating some mild symptoms or some difficulty in social, occupational, or school functioning but generally functioning pretty well with some meaningful interpersonal relationships. The VA clinician stated that the Veteran had recently decided to divorce his second wife. "He is chronically depressed with panic attacks and recurrent symptoms of PTSD." The Axis I diagnoses included mild to moderate PTSD. In March 2010, the Veteran complained he felt depressed and panicky. He reported that his wife had left during their separation and returned to Haiti and had been missing since the massive earthquake there in January 2010. "He is grieving and feeling guilty that she would still be alive if they had not separated." He lived alone. A sister, parents, and stepparents all lived nearby. "He goes to church frequently." He socialized with his neighbors. Mental status examination of the Veteran showed he was well dressed with normal muscle behavior, communication, and speech, full orientation, reported middle insomnia with daytime impairment, normal appetite, normal thought process, thought content with non-combat PTSD flashbacks, vivid reenactments, normal memory, and good judgment and insight. The Veteran's GAF score was 50, indicating serious symptoms or any serious impairment in social, occupational, or school functioning. The Axis I diagnosis was PTSD. On VA psychiatric examination on May 10, 2010, the Veteran's complaints included "I have nightmares, I wake up crying." His nightmares occurred 2-3 times a week. He also complained of "a lot of hopelessness" and suicidal ideation but no plan. He complained further of sleep difficulties. It was noted that the Veteran had been "interviewed for almost 3 hours before ultimately leaving the sessions unexpectedly out of frustration." The VA clinician also noted that "the bulk of the exam was completed when the Veteran left." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records, in extensive detail. The Veteran stated that he and his second wife had agreed on a mutual separation in December 2009. His wife had been living in Haiti at the time of the massive earthquake there in January 2010 and still was missing. "He believes that he is widowed but also does not have confirmation of that because of the nature of the trauma." He had no children. "He reports that he gets to sleep, no problems, but still has trouble staying asleep." A history of panic attacks "going back to childhood," major depressive disorder for 11 years "though there is indication that he was having problems with his mood prior to that," and "chronic symptoms of personality traits" was noted. The VA examiner stated that "there is a real mixture of depression and fluctuations in mood, dysthymia, personality difficulties, and likely somatoform disorder. That will be tricky to disentangle from the presence of quite significant medical problems resulting in pain and disability for this Veteran." He had no social relationships. He played guitar every day. He quit drinking in 1998 but continued smoking "about 10 a day, which is down from his typical 1 pack a day." The VA examiner stated that "it appears that the Veteran may have some difficulties with self-care...The Veteran does not appear to be actively involved in a positive way with family. Socially, the Veteran simply has no friends and does not socialize at all. He also has very little in the way of leisure pursuits considering that he is not working." Mental status examination of the Veteran in May 2010 showed he was casually and appropriately dressed with "some difficulty describing his symptoms," some "mild but palpable difficulty" in thought process, misunderstanding interview questions which had to be repeated "sometimes several times," tangential answers "often starting to answer the question, but trailing off in a direction that meandered from the original point," illogical answers at times, and no reported history of delusions or hallucinations "though, again there, is reference in the record to a history of persecutory delusions, but the Veteran is not aware of what that refers to, nor was it described by his treaters at the time." The Veteran had good eye contact. "He admits to suicidal thoughts, but has no plan or intention and reports that he would not act on those thoughts. He has no homicidal ideations." He reported managing his activities of daily living "very well" and full orientation. He also reported some short- and long-term memory impairment "for the last couple of years." He denied any obsessive or ritualistic behavior or speech difficulties. His mood was stable. The VA examiner stated: Also, the Veteran contradicted himself throughout the evaluation. It was interesting that prior to our meeting, as I set him up for testing, he reported that people have not documented his comments accurately: to look at the history, and experience that he contradicted himself with me, it is my sense that the Veteran is confused. He did quite frequently contradict himself and it was actually when I was pointing that out to him that he became frustrated and left...He just reached a point where he could not sustain himself in the appointment anymore, and the contradictions did not appear to be part of the deliberate process to confuse because they did not really make sense. They appeared to be based on the Veteran's own confusion and misunderstanding. The VA examiner noted that, during his first several years of treatment with VA, the Veteran did not report any in-service trauma or symptoms of PTSD. He currently reported "intrusive thoughts 3 to 4 times a week that are fleeting. He is reporting nightmares occurring 2 to 4 times a week with the onset of about 5 years ago." The VA examiner stated that the Veteran's PTSD "while present, does not appear to be causing any functional impairment that I was able to determine" and assigned a GAF score of 65/70 for this diagnosis. This examiner also stated that there were other mental disorders other than PTSD "that are independently responsible for his impairment." The Axis I diagnoses included late onset PTSD by history. On VA outpatient treatment on May 13, 2010, the Veteran's complaints included nightmares 3 times a week, sleep difficulty. The Veteran lived alone and denied suicidal ideation. Mental status examination of the Veteran showed he was quiet, speech within normal limits, goal-directed and linear thought process and content without psychosis, intact memory, and fair insight and judgment. The Veteran's GAF score was 65. The Axis I diagnoses included PTSD by history. In a May 17, 2010, addendum to the May 10, 2010, VA examination, the VA examiner opined that it was at least as likely as not that the Veteran's presented symptoms of PTSD were related to "the helicopter crash the Veteran has reported witnessing and responding to personally. It is less likely than not that the bulk of his psychological problems are related to this exposure nor is he stating his ability to work is impaired by these symptoms. He also had multiple other traumas and is reporting no PTSD symptoms from any other traumas." A VA PTSD screen on May 20, 2010, was positive. On VA outpatient treatment in July 2010, the Veteran's complaints included "nightmares but not every night. He still has some dreaming of war during the day. He struggles with his PTSD symptoms. He has insomnia most nights and falls asleep about the 3rd night when he [is] physical exhausted. He falls asleep easily but he wakes up quickly in panic. He does not fall back to sleep easily." The Veteran also "worries about a lot of trivial things...[and] struggles with isolating himself from other people." He denied any suicidal or homicidal ideation or auditory or visual hallucinations. Mental status examination of the Veteran showed he was calm, in no acute distress, dressed appropriately, normal speech, intact cognition, no suicidal or homicidal ideation, "no current evidence of psychosis," good insight, and intact judgment. The Veteran's current GAF score was 55, indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning. The diagnoses included PTSD. It was noted that the Veteran had a good response to Lamictal "and will benefit from restarting this medication[]." In an August 2010 statement, the Veteran asserted that he experienced nightmares 4-7 nights a week, nightmares during daytime naps, and reported panic attacks. He also asserted that he experienced "crying and screaming while I struggle to sleep." On VA outpatient treatment in October 2010, it was noted that: [The Veteran] states that he has been doing better. He believes that his medications are working effectively...He has not been crying anymore. He is still taking medications for panic attacks since he has these on a daily basis. He continues to have nightmares 4-7 nights a week and he has to take medications to calm him down. He gets to sleep fine but he has problem[s] staying asleep. He has occasional night sweats...He still has flashbacks during the day but he also has dreams during the day. The dreams bother him more than anything else. He gets out of the house on a daily basis and is able to socialize with his neighbors. He denies having any rage episodes. He has some uneasiness around crowds. The Veteran also denied any suicidal or homicidal ideation or auditory or visual hallucinations. Mental status examination of the Veteran was unchanged from July 2010. The Veteran's GAF score was 55. The assessment was that the Veteran "has improvement in his mood but PTSD symptoms remain well entrenched." In a December 2010 addendum to the May 2010 VA examination, the VA examiner who conducted the May 2010 VA examination stated that: Though the Veteran reports symptoms consistent with PTSD, he had never reported or complained of those symptoms for many years of treatment for other conditions. Regardless, he could have a late onset form of PTSD, especially if other symptoms had undergone significant improvement. Another reservation related to the 'cause' of the PTSD, as these symptoms, while endorsed by the Veteran, also overlap with other psychological conditions, including diagnostic problems the Veteran has consistently reported and been treated for over many years. This examiner noted that it was difficult to provide a differential diagnosis for the Veteran's PTSD symptoms because of his history of significant multiple head trauma "which can cause a multitude of mood, personality, anxiety, and cognitive symptoms. As a result, it is unknown to this examiner how to consider a differential diagnosis." This examiner also noted that there was "some evidence of contradictory reports of [the Veteran's] symptoms over time which don't appear to be fully accounted for by a change in his clinical course over time." This examiner concluded that the Veteran's report of experiencing PTSD symptoms as a result of witnessing the in-service helicopter crash was "suspect." On VA outpatient treatment in September 2011, it was noted that [The Veteran] states that he has been doing better. Medications have been effective in reducing his anxiety and Paxil helps with his depressive mood. He has not been taking the Lamictal and the Prazosin when he restarted the Paxil. He is getting out more and is sociable. He plays music more often than before. He is talking to more people and made new friends recently...He is sleeping better but his sleep is not as great as he wants it to be. He feels like life has been good to him...His concentration and memory are fine. He denies having any feelings of hopelessness or helpless. He has not been crying since he restarted Paxil. He denies [the] presence of suicidal or homicidal ideation as well as auditory and visual hallucinations. Mental status examination of the Veteran in September 2011 showed he was calm, in no acute distress, appropriately dressed, normal speech with soft volume, intact cognition, "no current evidence of psychosis," good insight, and intact judgment. The Veteran's GAF score was 60. The diagnoses included PTSD. The VA clinician stated that the Veteran was "stable at present." In March 2012, the Veteran reported that "he has been doing better lately - no longer having crying spells, mood has been better ("the doom and gloom has gone away")." He still was experiencing nightmares "which wake him at times. He sleeps 3-5 [hours] a night, but states this is a distinct improvement as in the past he has gone multiple days [without] sleep and felt very tired during those times." Mental status examination of the Veteran showed no acute distress, normal speech with a "very slightly slow rate," logical, linear, goal-directed thought process without loosening of associations or flight of ideas, thought content without "prominent delusions or preoccupations," no evidence of suicidal or homicidal ideation, no evidence of auditory or visual hallucinations, grossly intact cognition, and "restricted" insight and judgment. The VA clinician stated that the Veteran's PTSD was "improved now." The Axis I diagnoses included PTSD. A VA PTSD screen in May 2012 was positive. On VA PTSD Disability Benefits Questionnaire (DBQ) in June 2012, the Veteran's complaints included nightmares, panic attacks, sleep problems, self-isolating, irritability, and "brief and fleeting" intrusive thoughts and flashbacks. His nightmares occurred 1-7 nights a week. "Some weeks are bad and some are okay. He is obtaining about 4 hours of sleep per night." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. He experienced panic attacks 4-5 times a week. The VA examiner stated, "The Veteran meets PTSD criteria very minimally and this is because of bending towards the Veteran on some of [the] criterion. The only real clinical area it seems to affect is sleep." Mental status examination of the Veteran in June 2012 showed he was clean, neatly groomed, appropriately dressed, unremarkable psychomotor activity, hesitant speech, intact attention, full orientation, unremarkable, logical and goal directed thought processes, unremarkable thought content, reported persecutory delusions "once every three months or so," intact judgment, partial insight, mild sleep impairment which did not interfere with daytime activities, no hallucinations, inappropriate behavior, obsessive or ritualistic behavior, reported panic attacks, fair impulse control, no episodes of violence, and normal memory. The VA examiner concluded that the Veteran continued to meet the criteria for a PTSD diagnosis. This examiner also stated, "The Veteran's PTSD symptoms appear to be related to changes in impairment in functional status and quality of life...to a mild degree." This examiner also concluded that the Veteran "described mild PTSD symptoms. The worst being nightmares [sic]. With the PTSD being mild in nature, it is not at least as likely as not causing psychosocial impairment." This examiner concluded further that it was not possible to differentiate which of the Veteran's symptoms were attributable to his various psychiatric diagnoses. The rationale for this opinion was, "The Veteran has far to[o] many mental health diagnoses to try and differentiate each symptom. Ultimately, the PTSD symptoms are considered to be mild." The Veteran's GAF score for PTSD was 65. The diagnoses included PTSD. Analysis The Board finds that the preponderance of the evidence is against the Veteran's claim for an initial rating greater than 30 percent for PTSD. The Veteran contends that his service-connected PTSD is much more disabling than currently evaluated. The record evidence does not support his assertions regarding worsening symptomatology attributable to his service-connected PTSD, however. It shows instead that this disability has been manifested by, at worst, complaints of nightmares, panic attacks, and sleep disturbance which are mildly disabling. The record evidence also shows that the Veteran's PTSD symptomatology has been, at worst, mildly disabling throughout the appeal period. There is no indication that the Veteran's service-connected PTSD is manifested by occupational and social impairment with reduced reliability or deficiencies in most areas or by total occupational and social impairment (i.e., a 50, 70, or 100 percent rating under DC 9411) such that an initial rating greater than 30 percent is warranted for this disability at any time during the appeal period. See 38 C.F.R. § 4.130, DC 9411 (2013). The April 2009 VA examiner concluded that the Veteran did not meet the full criteria for a diagnosis of PTSD although he conceded that, if the Veteran's reported in-service stressor of witnessing a helicopter crash and its aftermath could be corroborated, then a diagnosis of PTSD could be rendered. This examiner also noted that the only other PTSD symptom reported by the Veteran at that time, other than his reported in-service stressor, was "re-experiencing symptoms in the form of nightmares, which he says occur multiple times a week." This examiner further found it "actually rather remarkable" that the Veteran's claims file showed multiple inpatient and outpatient treatment visits for a variety of psychiatric problems but no valid diagnosis of PTSD was rendered during such treatment. This examiner also concluded that the Veteran's "periods of reduced psychosocial function have been related to alcohol dependence and depression and do not appear to be related to PTSD." Although the Veteran apparently contacted VA's suicide hotline and threatened to kill himself, when questioned about this behavior following a referral from the suicide hotline to VA outpatient treatment in May 2009, the Veteran essentially conceded that he was not suicidal when he called the hotline and instead was upset at receiving a denial letter on his claim for benefits from VBA. The Veteran denied any homicidal ideation, auditory or visual hallucinations, or delusions. He lived with his second wife. Mental status examination of the Veteran showed he was casually dressed and neatly groomed, with spontaneous speech, linear and logical thought processes without looseness of associations or blocking, "thought content is significant for anger/resentment at VBA," full orientation, fair to poor judgment, and fair insight. The Veteran's GAF score was 60, indicating moderate symptoms, and the diagnoses included chronic PTSD. Subsequent mental status examination of the Veteran in December 2009 showed appropriate dress, normal gait, normal communication and speech, normal motor behavior, full orientation, reported abnormal sleep, reported nightmares, normal thought process, adequate judgment and insight, normal memory. The Veteran's GAF score had improved to 65, indicating some mild symptoms. The VA clinician stated in December 2009 that the Veteran had recently decided to divorce his second wife. "He is chronically depressed with panic attacks and recurrent symptoms of PTSD." The Axis I diagnoses included mild to moderate PTSD. It appears that the Veteran's psychiatric symptomatology worsened in early 2010 after his wife disappeared and likely died in the massive earthquake which hit Haiti in January 2010. In March 2010, it was noted that the Veteran was "grieving and feeling guilty that [his wife] would still be alive if they had not separated." Although he lived alone, his sister, parents, and stepparents all lived nearby and he attended church "frequently." He also socialized with his neighbors. Mental status examination of the Veteran showed he was well dressed with normal muscle behavior, communication, and speech, full orientation, reported middle insomnia with daytime impairment, normal appetite, normal thought process, thought content with non-combat PTSD flashbacks, vivid reenactments, normal memory, and good judgment and insight. The Veteran's GAF score was 50, indicating serious symptoms. Two months later, on VA examination in May 2010, it was noted that, "The Veteran does not appear to be actively involved in a positive way with family. Socially, the Veteran simply has no friends and does not socialize at all. He also has very little in the way of leisure pursuits considering that he is not working." The reasons for the discrepancy between what the Veteran reported in March 2010 and in May 2010 are not clear from a review of the record. The May 2010 VA examiner noted, however, that "the Veteran contradicted himself throughout the evaluation." The May 2010 VA examiner also noted that, during his first several years of treatment with VA, the Veteran did not report any in-service trauma or symptoms of PTSD. This examiner stated that the Veteran's PTSD "while present, does not appear to be causing any functional impairment that I was able to determine" and assigned a GAF score of 65/70 for this diagnosis. The Axis I diagnoses included late onset PTSD by history. After the Veteran was restarted on medication (Lamictal), he reported that his PTSD symptomatology had improved on VA outpatient treatment in October 2010. He had stopped crying. "He gets out of the house on a daily basis and is able to socialize with his neighbors. He denies having any rage episodes. He has some uneasiness around crowds." The assessment was that the Veteran "has improvement in his mood but PTSD symptoms remain well entrenched." The May 2010 VA examiner noted in a December 2010 addendum that the Veteran's report of experiencing PTSD as a result of an in-service helicopter crash was "suspect." This opinion was fully supported. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Veteran's PTSD symptomatology again improved after his medications were changed as he noted on VA outpatient treatment in September 2011. At that time, he reported "that he has been doing better." His medications effectively reduced his anxiety and improved his mood. "He is getting out more and is sociable. He plays music more often than before. He is talking to more people and made new friends recently...He is sleeping better but his sleep is not as great as he wants it to be. He feels like life has been good to him...His concentration and memory are fine. He denies having any feelings of hopelessness or helpless. He has not been crying since he restarted Paxil. He denies [the] presence of suicidal or homicidal ideation as well as auditory and visual hallucinations." The VA clinician found "no current evidence of psychosis on mental status examination of the Veteran. The Veteran's GAF score was 60. The VA clinician also stated that the Veteran was "stable at present." A different VA clinician noted that the Veteran's PTSD had "improved" following subsequent outpatient treatment in March 2012. At the Veteran's most recent VA PTSD DBQ in June 2012, the VA examiner stated, "The Veteran meets PTSD criteria very minimally and this is because of bending towards the Veteran on some of [the] criterion. The only real clinical area it seems to affect is sleep." This examiner also stated, "The Veteran's PTSD symptoms appear to be related to changes in impairment in functional status and quality of life...to a mild degree." Following mental status examination of the Veteran, the VA examiner concluded that the Veteran "described mild PTSD symptoms." This examiner also concluded that the Veteran's PTSD was not causing psychosocial impairment. The Veteran's GAF score for PTSD was 65, indicating mild symptoms. The June 2012 VA examiner's opinions regarding the severity of the Veteran's service-connected PTSD symptomatology were fully supported. See Stefl, 21 Vet. App. at 124. The evidence does not indicate that the Veteran experienced occupational and social impairment with reduced reliability and productivity (i.e., at least a 50 percent rating under DC 9411) such that an initial rating greater than 30 percent for his service-connected PTSD is warranted. See 38 C.F.R. § 4.130, DC 9411 (2013). The Veteran also has not identified or submitted any evidence, to include a medical nexus, which demonstrates his entitlement to a higher initial rating for his service-connected PTSD. In summary, the Board finds that the criteria for an initial rating greater than 30 percent for PTSD have not been met. Extraschedular The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected PTSD. 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular evaluation assigned for the Veteran's service-connected PTSD is not inadequate in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected PTSD. This is especially true because the 30 percent rating currently assigned for the Veteran's PTSD effective November 25, 2008, contemplates mild to moderate disability. Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. The record evidence indicates that multiple VA treating clinicians have attributed the Veteran's difficulties with employment to other psychological diagnoses than his service-connected PTSD. In light of the above, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to an initial rating greater than 30 percent for PTSD is denied. ____________________________________________ JENNIFER HWA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs