Citation Nr: 1423691 Decision Date: 05/23/14 Archive Date: 05/29/14 DOCKET NO. 08-20 160 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD D. Chad Johnson, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1968 to June 1970. , He died in September 2011 while his claim was pending. The appellant is the Veteran's surviving spouse. She is pursuing the appeal as a substituted claimant under the provisions of 38 U.S.C.A. § 5121A (West 2002 & Supp. 2013). This matter comes before the Board of Veterans' Appeals (Board) from a September 2007 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California, which granted service connection for PTSD and assigned an initial 30 percent disability rating, effective May 29, 2007. The Veteran disagreed with the initial rating assigned. In April 2010, the Veteran's representative, with his consent, submitted a written request to cancel his prior request for a videoconference hearing before the Board. Therefore, the Veteran's hearing request is withdrawn. 38 C.F.R. §§ 20.702(e), 20.704(e) (2013). In October 2011, the RO received notice of the Veteran's death from the appellant and the Social Security Administration (SSA). Later that same month, the appellant filed VA Form 21-534, Application for Dependency and Indemnity Compensation (DIC), Death Pension, and Accrued Benefits by a Surviving Spouse or Child. In April 2012, the appellant filed VA Form 21-601, Application for Accrued Amounts Due a Deceased Beneficiary. In March 2014, VA notified the appellant that she was approved to serve as a substitute claimant to pursue the Veteran's existing claim. Because the Veteran timely appealed the issue of entitlement to a higher initial disability rating for PTSD in excess of 30 percent, and because the appellant has been found to be a proper substitute claimant in this case, this issue is properly before the Board. 38 U.S.C.A. § 5121A (West 2002). The Board notes that the March 2014 notice indicated that the RO had not received a VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, from the appellant. However, a review of the Virtual VA system indicates that the appellant submitted a valid VA Form 21-22 in favor of the Military Order of the Purple Heart of the U.S.A. (MOPH) in October 2011. Indeed, an April 2014 notice that the appeal had been certified to the Board included MOPH as a recipient. The Board finds no motion to revoke the October 2011 appointment; thus, the appellant continues to be represented by MOPH. The Board has reviewed the Veteran's physical claims file and any electronic records maintained in the Virtual VA system and Veterans Benefits Management System (VBMS) to ensure complete review of the evidence of record. FINDINGS OF FACT 1. Prior to January 22, 2008, the Veteran's PTSD was manifested by symptoms of depression, irritability, sleep impairment with nightmares, hypervigilance, mild impairment of concentration and short-term memory, limited social activity, and some impairment of occupational ability, all of which most nearly approximates 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). 2. Since January 22, 2008, the Veteran's PTSD was manifested by symptoms of depression, panic attacks more than once a week, impaired short-term and long-term memory, difficulty completing tasks, impaired judgment, impulsiveness, social isolation, and difficulty maintaining relationships, all of which most nearly approximates occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for an increased 50 percent disability rating for posttraumatic stress disorder (PTSD) have been met since January 22, 2008, but no earlier. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 41., 4.2, 4.3, 4.7, 4.21, 4.130, Diagnostic Code (DC) 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process VA has duties to notify and assist claimants in substantiating a claim for VA benefits. See, e.g., 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159 (2013). The Veteran initially claimed entitlement to service connection for posttraumatic stress disorder (PTSD) in May 2007. He was provided with notice regarding his claim in July 2007. Although it appears the Veteran was not provided with VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD, the Board finds this is harmless, and the Veteran related his stressor during an August 2007 VA examination and service connection was subsequently granted in a September 2007 RO decision. 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). Therefore, no additional discussion of the duty to notify regarding the initial rating of the Veteran's PTSD is required. Regarding the duty to assist, the Veteran's service treatment records, VA treatment records, and private treatment records have been obtained and associated with the claims file. At the time of his May 2007 claim, the Veteran reported he had been seen at a local Vet Center. The Board notes that the claims file does not contain any Vet Center records; however, the Veteran did not submit any Vet Center records or authorize VA to seek such records on his behalf. Moreover, the Board finds no indication that such records contain information that is inconsistent with or non-duplicative of VA and private treatment records contained within the claims file which adequately describe the Veteran's psychiatric history and condition. Therefore, the Board finds any error in the failure of VA to obtain the Veteran's Vet Center treatment records is harmless and remand to obtain such records is unnecessary. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (finding that remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). As noted above, the Veteran was afforded a relevant VA examination in August 2007, and the examination report has been associated with the claims file. The Board finds the examination and resulting opinion is adequate and provides a sound basis that allows the Board to address the applicable rating criteria. The VA examiner personally interviewed and examined the Veteran, considered his reported history, provided sufficiently detailed descriptions of the claimed disability, and provided analysis to support the resulting opinion, including the information necessary to evaluate the Veteran's PTSD. No additional relevant evidence has been identified by the appellant or her representative. As all necessary development has been accomplished, no further notice or assistance is required for a fair adjudication of the claim on appeal and, therefore, appellate review may proceed without prejudice to the appellant. II. Increased Rating - PTSD The Veteran, and now the appellant, has asserted entitlement to a higher initial disability rating in excess of 30 percent for PTSD. For the reasons that follow, the Board concludes that an increased rating of 50 percent most closely approximates the Veteran's PTSD symptoms as of January 22, 2008, but no earlier. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2013). The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2013). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2013). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2013). When evaluating the level of disability from a mental disorder, VA also will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arises from the initial rating assigned, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, as discussed below, the Board has assigned a staged rating effective January 22, 2008. The Veteran's service-connected PTSD is currently evaluated as 30 percent disabling, effective from the date of his claim in May 2007, under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (2013). Under the applicable rating criteria, a 30 percent disability rating is assigned when there is 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 conversations 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). Id. A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is assigned 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 a work-like setting); inability to establish and maintain effective relationships. Id. Finally, a 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase 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 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms; a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. One factor for consideration is the Global Assessment of Functioning (GAF) score, which 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). A GAF score of 61 to 70 reflects 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. Scores ranging from 51 to 60 reflects moderate symptoms, such as flat affect and circumstantial speech, occasional panic attacks, or moderate difficulty in social or occupational functioning (e.g., few friends or conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious 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). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, 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). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). However, the rating schedule does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Accordingly, GAF scores do not automatically equate to any particular percentage in the Rating Schedule. Rather, they are but one factor to be considered in conjunction with all the other evidence of record. II.A. Prior to January 22, 2008 At the time of his PTSD claim in May 2007, the Veteran reported symptoms of depression, sleeplessness and nightmares, anger including towards Asian people, nervousness, and a quick startle response. A May 2007 initial psychosocial assessment by R.F., a private licensed clinical social worker (LCSW), contains diagnoses of PTSD and dysthymia. The Veteran presented with anger, avoidance of things reminding him of Vietnam, social isolation, poor sleep, and intrusive thoughts of Vietnam. He reported a good second marriage of 24 years and some contact with his children from a previous marriage. The Veteran appeared casually dressed and neatly groomed, and was cooperative but cautious. His affect was generally depressed, with clear speech and thoughts. There was no indication of hallucinations or delusions, either by history or observation. Long-term memory was intact but short-term memory was impaired. His concentration, judgment, and insight were all noted to be fair. The Veteran denied homicidal ideation, but admitted some passive suicidal thoughts in the past, with no plan or intent. The therapist diagnosed PTSD and assigned a current GAF score of 55, which is indicative of moderate symptoms. The Veteran was afforded a VA examination in August 2007 which resulted in a diagnosis of chronic PTSD and a current GAF score of 56. The examiner noted slightly depressed mood with congruent affect. The Veteran displayed logical speech with normal rate and flow. There was no evidence of hallucinations or delusions. Cognition and memory were noted to be okay, with good judgment and insight. The Veteran was not observed to be a danger to himself or others. The Veteran reported symptoms including poor sleep, varied appetite and weight, and some forgetfulness. The Veteran denied current suicidal thoughts or attempts or assaultive thoughts, although he reported shaking his wife at times during nightmares. He described his current marriage since 1982 as successful. Social activities reported included going out to dinner with his wife and participating with his grandchildren's activities and the Sons of Italy organization. The examiner noted symptoms including daily intrusive thoughts, nightmares every 2-3 weeks, intense reactions to stimuli including Oriental people, loud noises, and helicopters. The Veteran reported avoidance of war reports on the news and isolating himself from crowds. Increased arousal was present in the Veteran's sleep problems, irritability, some difficulty concentrating, hypervigilence, and exaggerated startle response. Based upon the above, the examiner documented clinically significant distress or impairment in social, occupational, or other important areas of functioning caused by "moderate level" PTSD. The Veteran also reported prior work history including 16 years at a petroleum plant where he progressed to a management position before his congestive heart failure in October 1999. The examiner noted that, when considering only the Veteran's PTSD, the Veteran was capable of work with some impairment due to decreased concentration and irritability. VA treatment records, including an active problem list from June 2005, reflect that the Veteran was diagnosed with depressive disorder in June 2003 and PTSD in August 2003. A treatment note from June 2005 documents that the Veteran was depressed and symptomatic even with prescribed medication. He was referred to the mental health center, including an evaluation for PTSD. A July 2005 primary care note documents that the Veteran was seen by the mental health center and started on Wellbutrin for depression. Thereafter, his psychiatric symptoms are documented as stable until an April 2007 addendum wherein the Veteran was advised to make an appointment with the mental health center due to his blunted affect and increased signs of depression. Following the VA examination in August 2007 discussed above, VA treatment records reflect the Veteran's PTSD was stable on prescribed medication until a worsening of symptoms was noted in March 2009, as discussed below. Overall, the Board finds that prior to January 22, 2008, the Veteran's PTSD was primarily manifested by symptoms of depression, irritability, sleep impairment with nightmares, hypervigilance, mild impairment of concentration and short-term memory, limited social activity, and some impairment of occupational ability. These symptoms are best approximated by the assigned initial 30 percent disability rating which accounts for some occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. Moreover, such symptoms do not more closely approximate the criteria required for an increased 50 percent disability rating. GAF scores assigned prior to January 22, 2008 were 55 and 56, respectively, indicative of moderate symptoms. However, the Veteran did not have complaints of a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impaired long-term memory; or impaired judgment or abstract thinking. Because the Veteran's PTSD symptoms prior to January 22, 2008 were not productive of occupational and social impairment with reduced reliability and productivity, the Board finds that the schedular criteria for an increased 50 percent rating were not met prior to January 22, 2008. As the criteria for an increased 50 percent rating have not been met, it follows that the Veteran also does not meet the more severe criteria for an increased 70 or 100 percent rating. II.B. Since January 22, 2008 A January 22, 2008 psychosocial update from R.F., LCSW, noted continuing symptoms including depression, intrusive thoughts of Vietnam stressors, impaired short-term memory and difficulty completing tasks, impaired judgment and impulsiveness, social isolation, and difficulty maintaining relationships. The therapist stated that it was difficult to separate some emotional symptoms related to the Veteran's physical problems from problems related to his PTSD; however, he noted that problems existed in all areas of the Veteran's life, and opined that the Veteran's PTSD symptoms more closely met the criteria for a 50 percent disability rating. The Veteran's June 2008 VA Form 9 substantive appeal contains his statements detailing his PTSD symptoms, including the following: difficulty understanding complex commands, impairment of long term memory including forgetting to finish things, severe motivation and mood disturbances, major problems with social relationships except for with his wife, panic attacks that range from 2-3 times per week to only once per week, reclusiveness, trouble being around authoritative people, a lack of reliability, and recurring nightmares of his combat stressors during Vietnam service. The appellant submitted a December 2008 lay statement detailing her experience dealing with the Veteran's PTSD. She reported that he acts impulsively, without thinking about the consequences of his actions. She discussed his trouble sleeping, including nightmares when she would have to wake him. She noted that the Veteran was guarded and does not know how to show emotion, including that he had no contact with his son in the past three years. She stated that his flashbacks were more frequent and noted the added stress of having her mother move in with them. In sum, she reported that she really did not know the Veteran, due to his psychiatric problems. A February 2009 psychosocial update from the Veteran's private therapist reflects that "[the Veteran's] condition appears to have worsened over the last several months." The Veteran reported panic attacks more than once a week, depression, passive thoughts of suicide, and decreased ability to maintain concentration. The therapist noted his short-term memory was increasingly worse as the Veteran often forgets simple tasks and responsibilities. The Veteran reported diminished motivation to help care for his aging mother and mother-in-law, as well as to participate in former pleasurable pursuits. The Veteran further reported problems of making and maintaining social relationships outside of his relationship with his wife and weekly group therapy sessions with other veterans. He continued to have daily intrusive thoughts of Vietnam stressors which interfere with his ability to function well on a daily basis. The therapist continued the diagnosis of PTSD and assigned a current GAF score of 52. Regarding the Veteran's occupational problems, he noted the even without the Veteran's congestive heart failure, the Veteran's PTSD would make it very difficult for anyone to work. VA treatment records document that in February 2008, the Veteran reported an increase in stress due to his mother-in-law moving in with his family, as well as financial stress and problems with his children. The Veteran reported that even with all the reported stressors, his mood had been relatively stable and his current medication regimen was working fairly well. The nurse practitioner noted that the Veteran was appropriately dressed and well groomed, with congruent affect, relatively stable mood, and no evidence of thought disorder. A GAF score of 51 was assigned. In March 2009, the Veteran reported an argument with his wife the previous night and acute stressors since his mother-in-law moved in the previous year. He reported an increase in depression symptoms, sleep problems, and intrusive thoughts of Vietnam. He reported his main issue was irritability, agitation, and a short fuse. The nurse practitioner added buspar to his prescribed medication list to address his uncontrolled anger and irritation. In May 2009, the Veteran reported more stability at home, and the prescribed buspar was helping to control irritability and agitation, although his PTSD symptoms continued to bother him and affect his daily life. In August 2009, the Veteran reported feeling like he was in a daze in the last several months. The nurse practitioner noted this was likely associated with the addition of buspar medication, and he decided to taper and discontinue it. Overall, the Veteran's PTSD and depression were noted to be well controlled, and a GAF score of 55 was assigned. Again in October 2009 and February 2010, the Veteran's PTSD was documented as stable, although he continued to report stress related to caring for his mother-in-law with Alzheimer's. The Veteran submitted a November 2010 statement that VA had increased his PTSD medications and he felt this should support a worsening of his condition. An October 2010 active medication list reflects that the Veteran was prescribed the following medication relative to his psychiatric conditions: alprazolam (0.25 mg daily), bupropion (300 mg daily), and citalopram (40mg). Aside from the alprazolam, which the Board notes was added sometime between May 2010 and October 2010, the Veteran was prescribed the same doses of bupropion and citalopram since July 2005. Thus, the medication levels by themselves, do not support the Veteran's report of worsening symptoms. The most recent mental evaluation of record is a November 2010 psychosocial update from R.F., LCSW, that notes a worsening of the Veteran's symptoms, including depression, passive suicidal thoughts, panic attacks more than once a week, isolation, impairment of short-term and long-term memory, poor concentration, poor ability to build and maintain relationships outside of his wife and therapy group, impaired sleep with nightmares, and poor judgment. A GAF score of 50 was assigned. Overall, since January 22, 2008, the Board finds the Veteran's PTSD symptoms are most closely approximated by an increased 50 percent disability rating. Assigned GAF scores during that time ranged from 50 to 55, indicative of moderate symptoms consistent with such a rating. The Veteran's symptoms include depression, panic attacks more than once a week, impaired short-term and long-term memory, difficulty completing tasks, impaired judgment, impulsiveness, social isolation, and difficulty maintaining relationships. These symptoms are best approximated by an increased 50 percent rating for occupational and social impairment with reduced reliability and productivity. The Board has considered the statements of the private therapist, and the competent lay statements of the Veteran and the appellant, which all document a worsening of symptoms; however, the Board finds that the Veteran's symptoms, as described in detail above, do not warrant a higher disability rating of 70 percent for any period on appeal. The Veteran did not display occupational and social impairment with deficiencies in most areas. While the Board notes that the Veteran had some passive suicidal thoughts, the Veteran denied having a specific plan or intent. He did not display obsessional rituals, or illogical and irrelevant speech. While the Veteran did report panic attacks more than once per week, there is no indication that this equates to near-continuous panic or depression that affected his ability to function independently. Additionally, the Veteran reported increased irritation, but this was treated successfully with medication and did not result in periods of violence. The Veteran did not display spatial disorientation or neglect of personal appearance or hygiene. Further, he did not display total occupational and social impairment required for a 100 percent disability rating. Thus, an increased rating of 50 percent, but no higher, for the Veteran's PTSD is warranted from January 22, 2008. IV. Extraschedular Consideration The Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1) (2013). The determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. 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 adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. In this case, the lay and medical evidence fail to show unique or unusual symptomatology regarding the Veteran's service-connected PTSD that would render the schedular criteria inadequate. The Veteran's symptoms, including depression, anxiety, sleep impairment with nightmares, panic attacks, hypervigilance, impaired memory, and social isolation, are contemplated in the rating assigned; thus, the application of the Rating Schedule is not thwarted. Further, neither the Veteran nor the appellant have argued that his symptoms are not contemplated by the rating criteria; rather, the Veteran merely disagreed with the assigned initial evaluation for his level of impairment. In other words, he did not have any symptoms from his service-connected disorder that are unusual or different from those contemplated by the schedular criteria. Accordingly, referral for consideration of an extraschedular rating is not warranted, as the manifestations of the Veteran's disability are considered by the schedular rating assigned. Based on the foregoing, the Board finds the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321; Thun, 22 Vet. App. 111. ORDER An increased 50 percent disability rating for posttraumatic stress disorder (PTSD) is granted effective January 22, 2008, but no earlier. ____________________________________________ MATTHEW D. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs