Citation Nr: 1036680 Decision Date: 09/28/10 Archive Date: 10/05/10 DOCKET NO. 09-21 613 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to a disability rating in excess of 70 percent for service-connected posttraumatic stress disorder. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1952 to October 1955. His awards and decorations include the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2008 rating decision of the Columbia, South Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA). The rating decision denied the Veteran's claim of entitlement to an increased evaluation, in excess of 70 percent, for posttraumatic stress disorder. In September 2009, the Veteran, accompanied by his spouse and authorized representative, appeared at a videoconference hearing held before the below-signed Acting Veterans Law Judge. A transcript of that hearing has been associated with the claims file. As part of its present decision, the Board has again reviewed the record in depth, including with regard to determining whether the Veteran was afforded his due process rights in the development of evidence through testimony. At the hearing, the Veteran was afforded an extensive opportunity to present testimony, evidence, and argument. The transcript reveals that appropriate colloquies were conducted between the Veteran and the undersigned, in accordance with Stuckey v. West, 13 Vet. App. 163 (1999) and Constantino v. West, 12 Vet. App. 517 (1999) (relative to the duty of hearing officers to suggest the submission of favorable evidence). The hearing transcript also reflects that the undersigned conducted the hearing in accordance with the statutory duties to "explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position," pursuant to 38 C.F.R. § 3.103(c)(2), as recently explained by the Court in Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the transcript of the hearing reflects that the undersigned identified the material issues and asked the Veteran about the existence of any outstanding pertinent evidence. As such, the Board finds that the hearing officer's duties in 38 C.F.R.§ 3.103(c)(2) were met and that the Veteran was not prejudiced by the hearing that was provided. See Bryant, 2010 WL 2633151 at 8 (citing to 38 U.S.C. § 7261(b)(2); Shinseki v. Sanders, 129 S. Ct. 1696, 1704 (2009)). In order to clarify the claim on appeal, since the Veteran has contended that he is entitled to additional service-connected disability benefits for posttraumatic stress disorder dating back to his initial 1955 claim (see statements of March and August 2008), the Board notes that he was, since 1955, receiving benefits for a mental disorder. The diagnosis of this mental disorder has changed from a conversion reaction with anxiety, to an anxiety reaction with schizoid features, to posttraumatic stress disorder; however, the claims file reflects that the underlying disease or injury has not changed. Specifically, a November 1955 VA examination report notes the precipitating factor of the Veteran's mental disorder (then diagnosed as a conversion reaction) was "battle experience," the claims file reflects a progression of diagnoses attributed to his experiences in Korea, and a May 2008 VA examiner notes that (after the Veteran's service in Korea) he had always experienced posttraumatic stress disorder. "The factual basis of a veteran's claim for service connection is the veteran's underlying disease or injury, rather than the symptoms of that disease or injury. " Boggs v. Peake, 520 F.3d 1330, 1334 (Fed. Cir. 2008). As such, the Board declines to refer any additional claims since the record does not reflect that the Veteran experiences separate, distinct mental disorders and he has received compensation for a service-connected mental disorder since 1955. FINDING OF FACT The evidence shows that the Veteran's posttraumatic stress disorder does not result in 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. CONCLUSION OF LAW The schedular criteria for the assignment of an evaluation in excess of 70 percent have not been met. 38 U.S.C.A. § 1155 (West 2002) ; 38 C.F.R. § 4.130, Diagnostic Code 9411 (2009). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Board has considered the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 and Supp. 2009). The regulations implementing VCAA have been enacted. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2009). VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103; see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied with respect to the issue decided herein. The notice and assistance provisions of VCAA should be provided to a claimant prior to any adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO sent the Veteran a letter in April 2008, prior to adjudication, which informed him of the requirements needed to establish a claim of entitlement to an increased evaluation. In accordance with VCAA, the letter informed the Veteran what evidence and information he was responsible for obtaining and the evidence that was considered VA's responsibility to obtain. Additional medical records were subsequently added to the claims file. The Veteran was notified in a separate August 2008 letter, in compliance with Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), of the necessity of providing medical or lay evidence demonstrating the level of disability and the effect that the disability has on employment as well as the evidence necessary to establish a claim of entitlement to an increased evaluation under the specific diagnostic code assigned to his disability. The Board observes that the U.S. Court of Appeals for Veterans Claims (Court) subsequently held that VCAA notice in a claim for increased rating need not be "veteran specific" and need not include reference to impact on daily life or rating criteria. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). The Veteran also was informed in the August 2008 letter as to how VA determines appropriate disability ratings and sets effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Although the August 2008 letter was sent to the Veteran subsequent to the initial adjudication, he is not shown to be prejudiced by the timing of the notice. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a statement of the case (SOC) or SSOC, is sufficient to cure a timing defect); Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (prejudicial error analysis is not necessary if subsequent notice, followed by readjudication, has been provided). As such, the Board finds that the duty to notify has been met. VA has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. VA has obtained records of VA medical treatment and the Veteran has reported that he does not receive private treatment. See Hearing Transcript on page 10. VCAA also requires VA to provide a medical examination when such an examination is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159 (2009). The Veteran was afforded a VA examination for his service-connected posttraumatic stress disorder in May 2008; an addendum was issued in July 2008. The Board has found these reports to be thorough and consistent with the Veteran's treatment records. Accordingly, they are adequate and may be considered in deciding his claim. Accordingly, an additional examination is not required. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995); cf. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). After having carefully reviewed the record on appeal, the Board has determined that the notice requirements of VCAA, and VA's duty to assist the Veteran in the development of his claim, have been satisfied. Further, the Board concludes that all available evidence pertinent to the claim has been obtained and there is sufficient medical evidence on file in order to make a decision. As the Veteran has been given ample opportunity to present evidence and argument in support of his claim, the Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2009). Mental Disorders Rating Law Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002). Evaluations of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2 (2009). If there is a question that arises as to which evaluation to apply, the higher evaluation is for application if the disability more closely approximates the criteria for that rating; otherwise, the lower rating is for assignment. 38 C.F.R. § 4.7 (2009). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2009). Although a veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1 (and see Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991)), where, as here, service connection has already been established, and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). A veteran 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 following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Currently, the RO has assigned the Veteran's service-connected mental disorder a disability rating of 70 percent, effective July 2000 per an April 2001 rating decision; a 50 percent rating was in effect since July 1976. The RO assigned those ratings pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, reflecting service connection for posttraumatic stress disorder. Prior to the application of Diagnostic Code 9411, the Veteran's service- connected mental disorder was evaluated as an anxiety disorder with schizoid features, rated as 30 percent disabling from December 1970, and a conversion reaction with anxiety, rated as 10 percent disabling from October 1955. The following discussion addresses the Veteran's level of disability from the time the increased rating claim was filed in March 2008. Francisco, 7 Vet. App. 55; Hart, 21 Vet. App. 505. According to 38 C.F.R. § 4.126(a), a mental disorder shall be evaluated "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 examination." The regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. 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. A 70 percent evaluation is assignable for posttraumatic stress disorder when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; 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. Id. A 100 percent evaluation for posttraumatic stress disorder is assignable with 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. In rating the severity of the Veteran's service-connected psychiatric disability under the criteria listed above, the Board is aware of the fact that psychiatric health care providers have their own system for rating psychiatric disability. This is the Global Assessment of Functioning (GAF) rating scale, and it is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM- IV); and see Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DSM-IV. The GAF scale score assigned does not determine the disability rating VA assigns, however, it is one of the medical findings employed in that determination. The medical evidence shows that GAF scores have been assigned during the pendency of this claim. An examiner's classification of the level of psychiatric impairment, by words or by a score, is to be considered, but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. A GAF score, however, is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. Massey v. Brown, 7 Vet. App. 204, 207 (1994). Regarding GAF scores potentially relevant to the case: A score from 80 to 71 indicates transient symptoms and expectable reactions to psychosocial stressors with no more than slight impairment in social, occupational, or school functioning; 70 to 61 represents some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships; 60 to 51 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning; 50 to 41 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). DSM- IV. Lastly, the Veteran's statements and testimony describing the symptoms of his service-connected disorder are deemed competent evidence. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. In March 2008, the Veteran was seen for mental health treatment by VA. The physician observed that he displayed normal speech, contents, and process without any problems with memory or word finding. The Veteran denied any suicidal ideation, and was assessed as having severe posttraumatic stress disorder. The Veteran reported to a follow-up appointment in April 2008, reporting that he was experiencing combat nightmares resulting in daily poor sleep. The professional behavioral counselor's and attending physician's report notes that combat-related nightmares appear to have worsened with no clear provocation, but described the Veteran as being appropriately dressed, cooperative, with a logical thought process, without auditory or visual hallucinations, with intact cognition, and without suicidal or homicidal ideations. His judgment is noted to be fair. A GAF score of 55 is reported. The Veteran was afforded a VA examination in May 2008, which resulted in diagnoses of posttraumatic stress disorder and generalized anxiety disorder. The examiner observed that the Veteran was service-connected for an anxiety disorder, but had some prior diagnoses of posttraumatic stress disorder and, as such, focused the examination and report on the "plausibility" of a posttraumatic stress disorder diagnosis. The examiner, after interviewing and examining the Veteran and conducting a thorough review of his claims file, opined that he "suffered from and continues to suffer from post-traumatic stress disorder symptoms" and that the current diagnosis of generalized anxiety disorder may represent a misdiagnosis. The Veteran reported hearing voices, experiencing nightmares, and isolation; the examiner noted that the claims file did show that he had displayed suicidal tendencies, but it was not known whether they were genuine. The examiner noted that the Veteran's thought processes and communication were generally on point, but perseverative - the Veteran is credited with helping to "comb[] through his substantial claims file documents." A GAF score of 47 was assigned. Additional objective findings from the May 2008 examination, consisting of the Veteran's specific responses to interview questions, are presented in a July 2008 addendum. A May 2008 treatment note observes that the Veteran reported an increase in combat-related nightmares. His affect was observed as congruent with mood and his thought process as logical; he did not display evidence of, or report, hallucinations or suicidal intent. His cognition was noted as intact and he was described as alert and appropriately dressed. His judgment was noted as fair, but his memory and concentration as poor. He was noted to have probable dementia of the Alzheimer's type. A GAF of 55 was assigned and the record reflects that the Veteran was admitted for treatment of delirium. In June 2008, the Veteran was seen for another mental health evaluation. The report notes that combat-related nightmares appear to have worsened with no clear provocation and that the diagnosis of a dementia may need to be re-examined. The Veteran was described as being appropriately dressed, cooperative, with a logical thought process, without auditory or visual hallucinations, intact cognition, and no suicidal or homicidal ideations. His judgment was noted as fair and his memory and concentration as good. A GAF score of 55 is reported and a later April 2008 addendum states the Veteran's diagnoses as posttraumatic stress disorder and major depression with anxiety. In later June 2008, the Veteran's file and mental status test results were reviewed by a psychiatrist who noted that the Veteran appeared to have no deficit that was consistent with dementia. The Veteran was seen again in July 2008 and was noted to appear alert and without memory deficits. The Veteran was described as being appropriately dressed, cooperative, with a logical thought process, without auditory or visual hallucinations, intact cognition, and no suicidal or homicidal ideations. His judgment was noted as fair and his memory and concentration as good. The VA health care provider noted that, due to a perfect score on the MMSE at the Veteran's last two visits, dementia appeared to be an inappropriate diagnosis. In August 2008, the Veteran was seen again and the reviewing psychiatrist noted that there was no evidence that he had dementia; certain prescription medications were discontinued and dementia was removed from his problem list. He was noted to have posttraumatic stress disorder and a depressive disorder with significant anxiety. The Veteran was described as being appropriately dressed, cooperative, with a logical thought process, without auditory or visual hallucinations, intact cognition, and no suicidal or homicidal ideations. His judgment was noted as fair and his memory and concentration as good. A GAF of 55 was assigned. At a separate August 2008 appointment, the Veteran reported experiencing extreme anxiety. In a later 2008 VA appointment for low blood pressure, a risk assessment was completed and the Veteran reported no thoughts of death or killing himself. He was seen again in September 2008 and was observed to be alert and able to converse, but stressed about his health. The Veteran was described as being appropriately dressed, cooperative, with a logical thought process, without auditory or visual hallucinations, intact cognition, and no suicidal or homicidal ideations. His judgment was noted as fair and his memory and concentration as good. A GAF of 55 was assigned. During an October 2008 pain evaluation, the Veteran reported that he was not at all depressed. During a general health screening that same month, the Veteran tested negative for posttraumatic stress disorder. Later that month, he was seen for evaluation of a speech condition - varying vocal pitch based on his level of aggravation; the Veteran reported that he has difficulty controlling the pitch of his voice when he gets upset. In a February 2009 health screening, the Veteran tested negative for posttraumatic stress disorder and depression. He stated at a check-up that same month that he felt as though he was better off dead. He repeated that sentiment at a March 2009 appointment, but was described as being appropriately dressed, cooperative, with a logical thought process, without auditory or visual hallucinations, intact cognition, and no suicidal or homicidal ideations. His judgment was noted as fair and his memory and concentration as good. A GAF of 55 was assigned. In March 2009, the Veteran wrote a statement to VA that his symptoms of posttraumatic stress disorder had increased. For example, he stated his symptoms caused him to "turn within." He described sleepless nights and waking up at 2:00am and not being able to go back to sleep. During an April 2009 appointment to evaluate recent chest pain, a risk assessment was performed and the Veteran reported no thoughts of suicide. A few months later, in July 2009, the Veteran was noted to have improved memory, but a lower mood beginning approximately three (3) months prior. However, he was again described as being appropriately dressed, cooperative, with a logical thought process, without auditory or visual hallucinations, intact cognition, and no suicidal or homicidal ideations. His judgment was noted as fair and his memory and concentration as good. A GAF of 55 was assigned. The Veteran was seen for group treatments, and in August 2009 was again interviewed by a professional behavioral counselor, whose findings were reviewed by a VA psychiatrist. The interview notes report that the Veteran expressed feeling upset at the lack of documentation in his medical record of worsening posttraumatic stress disorder symptoms. The counselor's treatment note reflects acknowledgment that his symptoms had worsened in regard to increased sleep disturbance and nightmares, increased anxiety and worry, and lowered mood with suicidal ideation. The Veteran's mental status was evaluated in August 2009 and he reported increased anxiety and thoughts about wanting to die. However, the results of his mental status examination revealed that he was appropriately dressed (the Board notes that the Veteran stated that he no longer cares about his appearance, but continues to shower and dress at his wife's urging), cooperative, with a logical thought process, without auditory or visual hallucinations, intact cognition, and no suicidal or homicidal ideations. His judgment was noted as fair and his memory and concentration as good. A GAF of 55 was assigned. At the September 2009 Board hearing, the Veteran's representative stated that the Veteran's symptoms met the criteria for a 100 percent evaluation. She pointed out a finding by an examiner that the Veteran had "significant anxiety" due to posttraumatic stress disorder, which she noted would indicate a very serious disability. She also noted the GAF score of 47 that an examiner had assigned. The Veteran's wife described the Veteran as very nervous, impulsive, and easy to anger. She stated he would tip toe around him. She testified the Veteran had been hospitalized two years ago after having a breakdown. He was in the hospital for 19 days. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). Having carefully considered the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against a finding that the Veteran's posttraumatic stress disorder symptoms more nearly approximate the criteria for a higher rating of 100 percent during the appeal period. Although the above medical evidence shows significant psychiatric symptomatology, as reflected by his current 70 percent rating, symptomatology required for an increased evaluation of 100 percent is not present. Specifically, the Veteran has never displayed persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (although the Veteran did note in August 2009 that he no longer cared about his appearance, he has not demonstrated an inability to maintain minimal hygiene), disorientation to time or place, memory loss for his own name or the names of close relatives. Although in May 2008, the Veteran did display poor memory and concentration, his judgment was noted as fair, his cognition intact, and his thought process logical. The evidence does not remotely suggest any gross impairment in thought processes or communication, as the Veteran has been consistently described as having normal speech and logical thought processes throughout the appeal. The testimony the Veteran provided at his Board hearing was entirely logical in connection with his claim for increase. This is evidence against a finding that there is any gross impairment in thought processes. The Veteran's medical records also do not reflect that he demonstrates many of the symptoms associated with a 70 percent disability: he has never shown obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression; impaired impulse control; spatial disorientation; or neglect of personal appearance and hygiene. The Veteran, at some point began reporting suicidal ideation even though he had consistently denied any suicidal and homicidal ideation throughout the appeal. See March 2008 VA treatment record (Veteran denied suicidal ideation); April 2008 VA treatment record (Veteran was without suicidal or homicidal ideations); May 2008 VA treatment record (Veteran did not display evidence of or report suicidal intent); June 2008, July 2008, August 2008, September 2008, February 2009, and April 2009 VA treatment records (no suicidal or homicidal ideations). The Board finds that the Veteran's subsequent reports of suicidal ideation are of questionable credibility. However, even accepting such symptom, it is contemplated by the 70 percent evaluation. The Board notes that the Veteran was diagnosed with delirium and possible dementia during the appellate period, but these diagnoses were not linked to his posttraumatic stress disorder and resolved after his prescription medication was adjusted. The Veteran contended in a March 2009 statement that his posttraumatic stress disorder symptoms had worsened. The Board notes that VA treatment records reflect some worsening in the areas of nightmares, sleep disturbance, isolation, and suicidal thoughts; however, these symptoms are contemplated in the 70 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. Just because symptoms worsen does not mean that they warrant an increased evaluation. Additionally, subsequent mental status evaluations continued to show no symptoms reflecting a 100 percent disability rating. The Veteran's GAF scores have been consistently measured at 55 during the period of this appeal, with the exception of an assignment of a GAF of 47 during the May 2008 VA examination. As noted above, a GAF of 60 to 51 indicates moderate symptoms and a score of 50 to 41 indicates serious symptoms; serious symptoms are described as suicidal ideation and severe obsessional rituals, which, again, are symptoms consistent with a 70 percent disability rating. DSM- IV. The Board notes that the undersigned got the impression while going through the claims file that the Veteran was working hard towards getting a higher evaluation, as opposed to his symptoms just naturally worsening. Based on a review of the treatment records, he seemed concerned about getting documentation showing a worsening of his symptoms, to the point that he expressed being upset over the lack of documentation in his medical record of worsening posttraumatic stress disorder symptoms. See August 2009 VA treatment record; see also May 2008 VA examination report ("This Veteran is insistent with respect to pursuing his claims, not to say that his claims are without merit, however.). There are other August 2009 VA treatment records showing the Veteran wanting the clinical records to document a worsening of his symptoms. That does not bode well for the Veteran's credibility. While the undersigned is not a medical professional, she is a lay person who is competent to make observations during the hearing such as whether someone's speech is logical during the hearing, whether the person is exhibiting grossly inappropriate behavior during the hearing, whether someone is disoriented to time or place, and whether the person has minimal personal hygiene.. The undersigned observed the Veteran to be well spoken, well groomed, logical, coherent, and cooperative and was fully aware of why he was at the hearing. Such observations confirm that the Veteran does not meet the criteria for a 100 percent evaluation. The Board understands that the undersigned saw the Veteran for a short period of time on one day; however, the observations during the hearing are essentially duplicative of the symptoms described by medical professionals in the clinical records throughout the appeal. In other words, the clinical findings that the Veteran had logical thought processes, was cooperative, had no auditory and visual hallucinations, had intact cognition, had good memory, and was appropriately dressed in the clinical records were observed during the hearing. The Veteran's representative argued at the hearing that the finding of "significant anxiety" was indicative of a severe psychiatric disorder. The Board agrees; however, the 70 percent evaluation contemplates a significant psychiatric disorder. The symptoms described under that evaluation-suicidal ideation, obsessional rituals, illogical speech, near-continuous panic/depression, impaired impulse control, spatial disorientation, neglect of personal appearance, inability to establish and maintain effective relationships-describe someone who is severely psychiatrically disabled. The Board is aware that the symptoms listed under the 100 percent evaluation are examples of the types and degree of symptoms that would warrant such evaluation, and that the Veteran need not have these particular symptoms in order to warrant a 100 percent evaluation. See Mauerhan, 16 Vet. App. 436. However, the criteria described under the 100 percent evaluation indicate a more serious disability than the Veteran has demonstrated throughout the appeal for the reasons described above. In fact, none of the evidence establishes that the Veteran meets the criteria for a 100 percent evaluation. The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The Court has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the Veteran has not required frequent hospitalizations for posttraumatic stress disorder. The Veteran was hospitalized during the appeal period; however, the temporary increase of the disability is contemplated by the 70 percent evaluation. See 38 C.F.R. § 4.1 ("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."). The manifestations of posttraumatic stress disorder are entirely contemplated by the schedular criteria. In sum, there is no indication that the average industrial impairment from the disability would be in excess of those contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. As reflected by the medical evidence of record, the Veteran's deficiencies are more than contemplated by the 70 percent rating. See 38 C.F.R. § 4.130. Therefore, an evaluation in excess of 70 percent is not warranted for the Veteran's posttraumatic stress disorder for the entire period. In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim for an evaluation in excess of 70 percent for service- connected posttraumatic stress disorder, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Total disability rating based on individual unemployability (TDIU). A total rating for compensation based upon individual unemployability is an element of all appeals of an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2001) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The record reflects that the Veteran is in receipt of a total rating for compensation based upon individual unemployability, effective July 2000. As such, although he has contended that his posttraumatic stress disorder renders him unemployable, the issue of entitlement to a total rating for compensation based upon individual unemployability has already been decided in his favor and need not be addressed in this decision. ORDER A rating in excess of 70 percent for service-connected posttraumatic stress disorder is denied. ____________________________________________ Alexandra P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs