Citation Nr: 0810944 Decision Date: 04/03/08 Archive Date: 04/14/08 DOCKET NO. 05-02 096 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for post-traumatic stress disorder (PTSD) and dysthymic disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Kroes, Associate Counsel INTRODUCTION The veteran served on active duty from August 1966 to August 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from the Huntington, West Virginia, Department of Veterans Affairs (VA) Regional Office (RO). The veteran was awarded service connection for PTSD and dysthymic disorder by an August 2003 rating decision. A 30 percent disability evaluation was assigned with an effective date of December 8, 1989. The veteran disagreed with the disability evaluation assigned and has perfected an appeal as to that issue. Prior to the award of service connection, the case was remanded by the Board for additional development on 3 separate occasions. The veteran was also afforded personal hearings before a Hearing Officer and a Member of the Board prior to the grant of service connection. Transcripts of those hearings are of record as well as a transcript of a cassette tape submitted by the veteran. FINDING OF FACT Throughout the appeal period, PTSD and dysthymic disorder were primarily manifested by depression, anxiety, irritability, impaired attention and concentration, nightmares, episodes of panic, isolative and avoidance behaviors, and exaggerated startle response. Severely impaired ability to establish and maintain effective or favorable relationships with people; psychoneurotic symptoms of such severity and persistence that there is severe impairment in the ability to obtain or retain employment; and occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood are not shown. CONCLUSION OF LAW With reasonable doubt resolved in favor of the veteran, the criteria for an initial evaluation of 50 percent, but no more, for PTSD and dysthymic disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code (DC) 9411 (2007); 4.132, DC 9411 (1996). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act (VCAA) (codified at 38 U.S.C.A. §§ 5100, 5102- 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007)) imposes obligations on VA in terms of its duty to notify and assist claimants. When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2007); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Id. Here, the veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, 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. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record VA treatment records, private treatment records, hearing transcripts, photographs, "buddy statements", service personnel records and service treatment records. There is no indication that any other treatment records exist that should be requested, or that any pertinent evidence has not been received. VA examinations were provided in connection with this claim. For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify (each of the four content requirements) and the duty to assist pursuant to the VCAA. See 38 U.S.C.A. §§ 5102 and 5103 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159(b), 20.1102 (2007); Pelegrini, supra; Quartuccio, supra; Dingess, supra. Any error in the sequence of events or content of the notice is not shown to have any effect on the case or to cause injury to the claimant. Thus, any such error is harmless and does not prohibit consideration of this matter on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Increased Rating The veteran asserts that throughout the appeal period he warrants a disability rating higher than 30 percent for PTSD and dysthymic disorder. Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Compensation for service-connected injury is limited to those claims which show present disability. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in cases such as this, involving the assignment of initial ratings following the initial award of service connection for PTSD and dysthymic disorder, VA must address all evidence that was of record from the date of the filing of the claim on which service connection was granted (or from other applicable effective date). Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). Accordingly, separate ratings may be assigned (at the time of the initial rating) for separate periods of time based on the facts found. Id. This practice is known as "staged" ratings. The Board acknowledges that in cases where entitlement to compensation has already been established a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Board notes that the applicable rating criteria for PTSD were amended effective November 6, 1996. 61 Fed. Reg. 52,695-52,702 (October 8, 1996). Pursuant to VAOPGCPREC 7-2003 (November 19, 2003), where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant normally applies, absent Congressional intent to the contrary. Therefore, the Board must evaluate the veteran's claim under both the former criteria in the VA schedule for Rating Disabilities and the current regulations in order to ascertain which version is most favorable to his claim, if indeed one is more favorable than the other. The Board will lay out the former criteria and the amended criteria for the benefit of comparing the criteria. Diagnostic Code 9411, in effect prior to November 6, 1996, states that Notes (1) to (4) following the rating formula should be read well before applying the general rating formula. 38 C.F.R. § 4.132, DC 9411 (1996). Prior to November 6, 1996, dysthymic disorder was also rated using the General Rating Formula for Psychoneurotic Disorders. See 38 C.F.R. § 4.132, DC 9405 (1996). Under the General Rating Formula for Psychoneurotic Disorders the criteria and evaluations for PTSD and dysthymic disorder are as follows, in relevant parts: Ability to establish and maintain effective or favorable relationships with people is severely impaired. The psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment - 70 percent. Ability to establish or maintain effective or favorable relationships with people is considerably impaired. By reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment - 50 percent. Definite impairment in the ability to establish or maintain effective and wholesome relationships with people. The psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment - 30 percent. Note (1): Social impairment per se will not be used as the sole basis for any specific percentage evaluation, but is of value only in substantiating the degree of disability based on all of the findings. Note (4): When two diagnoses, one organic and the other psychological or psychoneurotic, are presented covering the organic and psychiatric aspects of a single disability entity, only one percentage evaluation will be assigned under the appropriate diagnostic code determined by the rating board to represent the major degree of disability. When the diagnosis of the same basic disability is changed from an organic one to one in the psychological or psychoneurotic categories, the condition will be rated under the new diagnosis. 38 C.F.R. § 4.132, DC 9411 (in effect from February 3, 1998). The current regulations, in effect as of November 6, 1996, establish a general rating formula for mental disorders. 38 C.F.R. § 4.130 (2007). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 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). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. Under 38 C.F.R. § 4.130, DC 9411 (2007), the criteria and evaluations are as follows, in relevant parts: 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 worklike setting); inability to establish and maintain effective relationships - 70 percent 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 - 50 percent. Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) - 30 percent. 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. 38 C.F.R. § 4.126(a) (2007). 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. Id. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Initially, the Board notes that the veteran's claims file contains mental health treatment records and more than 10 VA psychiatric examinations conducted during the appeal period. These records show Global Assessment of Functioning (GAF) scores ranging from 30 to 65. The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Diagnostic and Statistical Manual of Mental Disorders 46-47 (4th ed. 1994). Although the GAF score does not fit neatly into the rating criteria, it is evidence, which the Court has noted the importance of in evaluating mental disorders. See Carpenter v. Brown, 8 Vet. App. 240 (1995). GAF scores ranging between 61 and 70 reflect 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, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more 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). 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; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). The Board has given consideration to the various GAF scores assigned to the veteran. Unfortunately, the range of these scores represents everything from behavior which is considerably influenced by delusions or hallucinations to some mild symptoms such as depressed mood and mild insomnia. Given that the period for consideration encompasses almost 20 years, some variation could be expected. However, in this case, some of the scores assigned by various examiners are vastly different during the same periods of time. For example, two VA examiners assigned the veteran a GAF score of 30 in August 1999 and stated that his highest GAF score in the last year was also 30. VA treatment records from that same month show a GAF score of 60 and a GAF score as high as 65 in the year prior. Given the discrepancies in the reported GAF scores, the Board has given more probative weight to the specifically reported symptoms and levels of functioning as these reports have remained more stable. The Board notes that the 2 VA examiners who assigned GAF score of 30 in August 1999 did not note any behavior that was considerably influenced by delusions or hallucinations. In fact, the examiners specifically noted that the veteran was negative for hallucinations or illusions and that there was no evidence of inappropriate behavior or suicidal or homicidal ideation. It was also noted that the veteran thoughts were logically organized and that his speech was of normal volume, rate, and cadence. The examiners did note that the veteran "does likely not care for himself, in that he does not prepare his own meals and does not present with good hygiene most of the time." Other VA examination reports show a starkly different picture regarding the veteran's care and hygiene. For example, a September 2000 VA examination report states that the veteran indicated that he was able to dress, clean and wash himself, and that he helps take care of his mother, cooks, cleans, likes to cut grass and watches television. He was reportedly casually dressed in jeans and T-shirt and unshaven. It is unclear if the August 1999 examination took place during a period of exacerbation of the veteran's disability. The examiners did indicate a belief that a 1998 abdominal surgery, which resulted in the veteran having a colostomy bag attached, likely exacerbated some of the veteran's PTSD symptoms. Other treatment records from that period of time describe the veteran as euthymic with mild to moderate anxiety and depression and an affect ranging from narrow to normal. As a final note regarding the August 1999 VA examination, it was noted that the veteran had "outbursts of anger;" no further explanation or examples were given, and no such outbursts are reported in the other competent medical evidence of record. After a careful review of the evidence, the Board finds that with reasonable doubt resolved in the veteran's favor, a 50 percent disability evaluation, but no more, is warranted for PTSD and dysthymic disorder. The preponderance of the evidence is against a finding that the veteran warrants an initial evaluation in excess of 50 percent for PTSD and dysthymic disorder at any time throughout the appeal period. Throughout the appeal period, PTSD and dysthymic disorder were primarily manifested by depression, anxiety, irritability, impaired attention and concentration, nightmares, episodes of panic, isolative and avoidance behaviors, and exaggerated startle response. These symptoms have on many occasions been described as at least moderate (and sometimes as marked and severe), and occupational and social impairment has been noted as a result. For example, a July 1990 VA examination report notes that the extent of the veteran's psychiatric problems appears to be moderate and his over-all prognosis is poor. A VA examiner in August 1993 noted that the veteran appears to have some severe psychological difficulties, and in April 1998 a VA examiner noted that the veteran has not functioned well over the years and has had great difficulty with occupational as well as interpersonal relationships. VA examiners in August 1999 noted the veteran was markedly depressed in mood and affect at that time. Similar reports have been made by other medical professionals throughout the years. Given the veteran's reported symptomatology, combined with the reports of the severity of his symptoms and the affect they have on his life, the Board finds that with reasonable doubt resolved in favor of the veteran the competent medical evidence of record shows that his disability picture throughout the appeal period has continually more nearly approximated the criteria required for a 50 percent rating (considerable industrial impairment) as opposed to the criteria for a 30 percent rating (definite industrial impairment). See 38 C.F.R. § 4.132, DC 9411 (1996). Accordingly, the veteran is entitled to an initial evaluation of 50 percent, but no more, for PTSD and dysthymic disorder. See 38 C.F.R. § 3.102, 4.7. The competent medical evidence of record supports a finding that the veteran does not warrant an initial evaluation in excess of 50 percent at any time throughout the appeal period considering the old criteria, or after November 6, 1996 considering the new criteria. A January 2003 VA examination report shows that the veteran complained of depression; anxiety; panic episodes with palpitations, smothering feeling, and hyperventilation; hopeless and helpless feelings; lack of desire; and being uncomfortable around people. The mental status examination revealed that the veteran was casually dressed, rather tense, anxious, edgy, depressed, oriented for time, place, and person. There was no evidence of any active hallucinations or delusions. Attention and concentration were impaired. Memory and recall were intact as was judgment. There was no evidence of any looseness of associations, flight of ideation or pressured speech. Fund of knowledge was adequate. There were no obsessive thoughts or compulsive actions. The veteran denied being actively suicidal or homicidal. The complaints and findings noted in the January 2003 VA examination are similar to those noted during the other numerous VA examinations and reports made during the course of this appeal. Considering the new criteria (in effect as of November 6, 1996), a 70 percent disability rating contemplates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. See 38 C.F.R. § 4.130, DC 9411 (2007). Examples of this type of impairment are: 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 worklike setting); inability to establish and maintain effective relationships. See id. All of these symptoms do not need to be shown for the 70 percent rating to be awarded. See Mauerhan, 16 Vet. App. 436; see also 38 C.F.R. § 4.7. Obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; and spatial disorientation are not shown by the competent medical evidence of record. Numerous medical reports state that the veteran is oriented, has normal speech, and does not have obsessional rituals. The veteran does report irritability, but periods of violence have not been reported (other than the unexplained entry about "outbursts of anger" in August 1999) and impaired impulse control is not shown in any other way by the evidence of record. The veteran has on many occasions denied any suicidal ideation; although, on a couple of occasions he has reported passive suicidal ideation. For example, in March 2007 the veteran admitted "fleeting occasional passive suicidal ideation with no plan." The veteran's occasional reports of occasional suicidal ideation combined with all of his symptomatology do not rise to the level of disability contemplated in the 70 percent disability evaluation. Recurrent episodes of panic and depression are shown by the evidence of record. The veteran's episodes of panic are typically described as palpitations, smothering feeling, and hyperventilation. Some medical reports note no episodes of panic. For example, see the August 20, 1999, VA examination report. Near continuous panic is certainly not shown. Episodes of depression have continually been reported. The effect of these symptoms has typically been described as moderate or moderate to severe. There is no indication that episodes of panic and depression combined with the veteran's other symptoms affect the veteran's ability to function independently, appropriately and effectively. It has been noted that the veteran is capable of completing daily activities. For example, a January 2003 VA examination report states that regarding his daily activities, the veteran is able to dress, clean, and wash himself. According to VA progress notes from August 2001 and April 2003, the veteran has been caring for his brother's grand children since his brother passed away. It was noted in the earlier report that the veteran "sounds like an excellent parent." The April 2003 VA progress note also explained that the veteran's mother recently passed away and that the veteran had lived with her and cared for her for the last 15 years. It would appear that the veteran is able to function independently, appropriately and effectively. The veteran has reported being irritable, edgy, uncomfortable around people, and other similar symptoms. It appears that he has some difficulty in adapting to stressful circumstances. Again, the effect of his symptoms has frequently been reported as moderate or moderate to severe. Such is reflected in a 50 percent rating. As with his other symptoms, at times greater disability has been noted; however, the overall disability picture does not support a finding that the veteran's difficulty in adapting to stressful circumstances, combined with his other symptoms, warrants a higher evaluation. The Board takes this opportunity to point out that generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. The competent evidence of record shows that the veteran has some difficulty with relationships. For example, the veteran's brother-in-law accompanied the veteran to an August 1999 VA examination and stated that the veteran does little but stay in his room. However, an inability to establish and maintain effective relationships is not shown. To his credit, subsequent to the above examination the veteran helped to raise his brother's grand children and he has also helped to care for his mother while she had Alzheimer's disease. (See January 16, 2003 VA examination report and August 2001 to April 2003 VA progress notes.) Considering the old criteria, a 70 percent disability rating contemplated that the ability to establish and maintain effective or favorable relationships with people is severely impaired and that the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. See 38 C.F.R. § 4.132, DC 9411 (1996). Note (1) of that code explained that social impairment per se will not be used as the sole basis for any specific percentage evaluation, but is of value only in substantiating the degree of disability based on all of the findings. See id., Note (1). The veteran's symptoms have been detailed above. While difficulty in establishing and maintaining effective work and social relationships is certainly shown, the veteran's reported symptoms do not cause a severely impaired ability to maintain effective or favorable relationships with people or to obtain or retain employment, as opposed to considerable impairment in these pursuits. The veteran is not working, and has not for a number of years, but the evidence of record simply does not show that this is a result of his PTSD and dysthymic disorder. At the veteran's most recent VA psychiatric examination, from February 2005, it was noted that his physical, emotional, and psychiatric condition including his PTSD has "definitely affected him socially, industrially, and occupationally." While an effect has been noted, severe impairment simply is not shown. The veteran has helped to raise his brother's grand children and cared for his mother for years while she had Alzheimer's disease. Such is not indicative of a person who is severely impaired in maintaining relationships or in obtaining and retaining employment. The Board is well aware that every symptom described in the different grades of disability does not need to be shown for entitlement to a higher rating. See 38 C.F.R. § 4.21. For all the reasons above, the Board finds that the veteran's disability picture more nearly approximates the criteria required for the 50 percent rating for PTSD (and psychoneurotic disorders) than the criteria required for the 70 percent rating. See 38 C.F.R. §§ 4.130, DC 9411 (2007); 4.132, DC 9411 (1996). As such, the Board finds that the veteran is not entitled to an evaluation in excess of 50 percent for PTSD and dysthymic disorder. See 38 C.F.R. § 4.7. The Board has considered all of the veteran's symptoms and not just those listed in the rating criteria. The veteran is competent to report his symptoms. To the extent that the veteran has asserted that he warrants more than a 50 percent evaluation, the Board finds that the preponderance of the evidence does not support his contentions, for all the reasons stated above. The Board is responsible for weighing all of the evidence and finds that the preponderance of it is against an initial evaluation in excess of 50 percent for PTSD and dysthymic disorder, and there is no doubt to be resolved. Gilbert, 1 Vet. App. at 55. The Board finds no basis upon which to predicate assignment of "staged" ratings. The Board notes it does not find that consideration of extraschedular ratings under the provisions of 38 C.F.R. § 3.321(b)(1) (2007) is in order. The Schedule for Rating Disabilities will be used for evaluating the degree of disabilities in claims for disability compensation. The provisions contained in the rating schedule will represent as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from disability. Id. In the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability. The governing norm in these exceptional cases is: a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id. The Board emphasizes that the percentage ratings under the Schedule are representative of the average impairment in earning capacity resulting from diseases and injuries. Section 4.1 of Title 38 of the Code of Federal Regulations states that, "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Thus, with this in mind, the Board finds that the veteran's symptoms that warrant the 50 percent evaluation for PTSD and dysthymic disorder are clearly contemplated in the Schedule and that the veteran's service-connected disability is not so exceptional nor unusual such as to preclude the use of the regular rating criteria. (CONTINUED ON NEXT PAGE) ORDER An initial evaluation of 50 percent, but no more, for PTSD and dysthymic disorder is allowed; to this extent the appeal is granted subject to the law and regulations governing the award of monetary benefits. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs