Citation Nr: 1127090 Decision Date: 07/20/11 Archive Date: 07/29/11 DOCKET NO. 07-21 424 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1962 to October 1966, with additional service in the Army Reserves. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a January 2007 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which increased the Veteran's disability rating for PTSD to 50 percent, effective November 13, 2006. The Veteran filed a notice of disagreement (NOD) with this rating and subsequently perfected an appeal. After the Veteran perfected his appeal, the RO issued an August 2007 rating decision continuing a 50 percent disability rating for his PTSD. In October 2010, the Board remanded the case for additional development. This development has now been completed and the case returned to the Board for further appellate review. FINDINGS OF FACT 1. From November 13, 2006, to November 16, 2010, the Veteran's PTSD has been productive of occupational and social impairment with reduced reliability and productivity. 2. From November 17, 2010, forward, the Veteran's PTSD has been productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent disabling for PTSD from November 13, 2006, to November 16, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (2010). 2. The criteria for an increased disability rating of 70 percent for PTSD, from November 17, 2010, forward, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the RO sent correspondence in November 2006 that informed the Veteran of what evidence was needed to establish the benefit sought, of what VA would do or had done, and of what evidence the Veteran should provide. In addition, the letter informed the Veteran of how effective dates are assigned. The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. There has been no prejudice to the Veteran, and any defect in the timing or content of the notices has not affected the fairness of the adjudication. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (specifically declining to address harmless error doctrine); see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). Thus, VA has satisfied its duty to notify the Veteran. VA must also make reasonable efforts to assist the Veteran 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. This duty includes assisting with the procurement of relevant records, including pertinent treatment records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA has also done everything reasonably possible to assist the Veteran with respect to his claim for benefits, such as obtaining medical records and providing the Veteran with VA examinations in January 2007 and November 2010. The Veteran has not indicated that he has received additional treatment for his service-connected shell fragment wound on the right buttock. The Board thus concludes that there are no additional treatment records outstanding with respect to that claim. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Increased Rating The Veteran and his representative contend, in substance, that the Veteran's PTSD is more disabling than currently evaluated. The Board will address whether a higher rating or ratings should have been granted for any time period during the appeal. Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § Part 4 (2010). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Part 4 (2010). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2010). When VA grants a claim for an increased rating, it may assign an effective date up to one year before the date the claimant's application for increase was received, provided it is factually ascertainable that an increase in disability occurred within that timeframe. 38 U.S.C.A. § 5110(b)(2); Hart, 21 Vet. App. 505, 509 (2007). Here, the relevant evidentiary window begins one year before the Veteran filed his claim for increased rating, and continues to the present time. The Veteran is currently assigned a 50 percent disability rating for PTSD in accordance with the criteria set forth in the Schedule for Rating Disabilities, 38 C.F.R. Part 4, Diagnostic Code 9411 (2010). Under the General Rating Formula for Mental Disorders, a 50 percent rating is warranted if it is productive of 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 rating is assigned for PTSD when the psychiatric condition produces 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. A 100 percent rating is assigned when there is total occupational or 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. The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV)). Scores ranging from 61 to 70 illustrate 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 illustrate 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 illustrate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning. The GAF score is only one factor to be considered in ascertaining the degree of impairment caused by the Veteran's psychiatric illness. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). A. Rating Higher than 50 percent from November 13, 2006, to November 16, 2010 In determining whether the Veteran is entitled to a rating higher than 50 percent since November 13, 2006, the Board has reviewed lay statements, VA outpatient treatment records, and the January 2007 VA examination report. Based on this evidence, the Board finds that the Veteran is not entitled to a disability rating in excess of 50 percent, during this time period at issue. Turning to the evidence of record, the Veteran submitted a November 2006 statement by his wife. The Veteran's wife noted that she had been married to the Veteran for 25 years, and stated that a day had not gone by that Vietnam had not played a part in their lives. Furthermore, she stated that about 13 years ago, the Veteran had a complete nervous breakdown, and that the past year was the worst year of their married life. She stated that the past year the Veteran had become more withdrawn and pulled away when she would get close to him. Additionally, she reported that he spent more time sleeping on the couch than he did in their bed. She added that he had nightmares and sweats, slept very few hours per night, and reported that he had threatened suicide twice and obsessed about his death. She also stated that he no longer wanted to go places and spent most of his time at home. Additionally, he had taken more sick days that year than any year in his work career. Lastly, she stated that he worried more about the future because he was retiring in four years. The Veteran was afforded a VA examination in January 2007 to evaluate his PTSD symptoms. The Veteran reported receiving treatment and medication for his mental health condition. Additionally, the Veteran stated that he suffered from fatigue due to his sleep problems. He reported that he binge drank to self medicate his symptoms of PTSD, and he admitted that he missed work on occasion because of being hung over. The Veteran also reported that he had been married to his second wife for 25 years and their relationship was good. However, the Veteran also added that he felt more comfortable separate from her than together, explaining that he liked to sleep on the sofa. Additionally, the Veteran reported that he had two children who he had a distant relationship with, denied having friends, and stated that he did not want to have any. Moreover, he stated that he is comfortable at home and did not want to leave home. Lastly, the Veteran reported that he had no history of suicide or violence. Upon examination, the Veteran was noted to be clean, neatly groomed, and appropriately and casually dressed. His speech was unremarkable, he had a full affect, with a depressed mood. The examiner found the Veteran to be cooperative, friendly, relaxed, and attentive. Additionally, the examiner noted the Veteran's thought process as rambling, and his thought content was listed as preoccupied with one or two topics. The examiner stated that the Veteran understood the outcome of his behavior. The Veteran did not have inappropriate or obsessive behavior. He reported having panic attacks that lasted about an hour, four to six times in the past two years. The Veteran also reported suicidal thoughts three to four times per month, but denied having intent or plan. The Veteran's impulse control was noted as good, without episodes of violence, and he reported that he sometimes did not pay attention to his personal hygiene and attributed it to his binge drinking. Additionally, the Veteran reported having problems with activities of daily living, such as household chores, shopping, sports, exercise, traveling, driving, and other recreational activities. The examiner noted that the Veteran's recent memory was moderately impaired. The Veteran reported that he loses focus all of the time, and the examiner noted that the Veteran demonstrated this in his interview. The Veteran reported that he did not like to participate in activities where many people were involved, such as weddings, funerals, or other gatherings. Additionally, he described feeling detachment from other people. He added that he isolates himself so that he will not have to interact with others. Moreover, the Veteran reported hypervigilence in constantly surveying his environment for danger even when he knew there was not realistically danger in the environment. The Veteran was noted to be incapable of managing his financial affairs. The Veteran reported that he was a full-time teacher, and stated that he missed two weeks of work in the last year for mental health days. The Veteran reported problems with occupational functioning, such as decreased concentration, difficulty following instructions, memory loss, and poor social interaction. The examiner diagnosed the Veteran with PTSD and alcohol abuse, stating that it appeared to be an attempt to medicate his symptoms of PTSD. Additionally, the examiner assigned the Veteran a global assessment of functioning (GAF) score of 51. The Veteran reported that his PTSD symptoms made his working as a teacher easier in that he did not form attachments to his students or teachers at school. Additionally, he stated that by not being connected to his coworkers, he was not involved in drama in the work place, which made his life easier. The examiner concluded that the Veteran's PTSD symptoms did not cause a decrease in his work efficiency because he had stated that his PTSD made him more efficient at work. However, the examiner also stated that his PTSD did severely impair his social functioning. Lastly, the examiner noted that the Veteran did not have total occupational and social impairment due to his PTSD symptoms. The Veteran submitted a statement in July 2007. The Veteran reported that he began to drink to self medicate his PTSD symptoms, so much so that at times he could barely function. Specifically, he reported that he drank until he passed out, which caused him to miss work and holidays with his family. Additionally, he reported that he was currently in after-care with the VA and attending AA meetings. The Veteran's outpatient VA treatment records document treatment for PTSD from the date of claim his claim. The records show that the Veteran was going through counseling and was medicated for his mental health conditions. Additionally, it was noted that the Veteran checked himself in to the VA for detox and a 30 day rehabilitation stay in July 2007. Furthermore, the psychiatry outpatient records noted the Veteran's struggles with thoughts of events he experienced in Vietnam, and his struggle with his drinking problem. The Veteran's doctor noted that he was oriented in all spheres, alert, talkative, and denied suicidal ideations. After a review of the evidence of record, the Board notes that the Veteran's symptoms appear to have stayed consistent from November 13, 2006, to November 16, 2010. Although the Veteran reports worsening of his symptoms, it would not constitute an increase in the rating of his PTSD. Even at their most severe, the Board finds that the Veteran's PTSD symptoms have been no worse than the criteria contemplated by a 50 percent rating under DC 9411: 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. 38 C.F.R. § 4.130, DC 9411. The Veteran's GAF score of record for this time period was noted by the January 2007 VA examination above. The Veteran's GAF score was 51, which is indicative of 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). The Board notes that an examiner's classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage rating to be assigned. See VAOPGCPREC 10-95. The Veteran's PTSD symptoms, such as occasional panic attacks and difficulty in social and occupational functioning, correspond with a GAF score of 51. At no time since the date of service connection has the Veteran been found to display occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: 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. 38 C.F.R. § 4.130, DC 9411. While the Veteran did report suicidal ideations, he did not exhibit other symptoms necessary to establish a 70 percent disability rating for PTSD. In this regard, the Board points out that the Veteran's speech and thought content were unremarkable at the January 2007 VA examination. Additionally, the VA examiner noted that the Veteran's appearance was clean, neatly groomed, and appropriately and casually dressed. The Veteran's VA outpatient treatment records also noted that he was oriented in all spheres, and the VA examination report was void of any history of hallucinations or delusions. The Veteran denied any obsessional rituals. Furthermore, the Veteran reported to the VA examiner that he had panic attacks four to six times in the past two years. Therefore, there was no indication in the claims file that the Veteran was in a nearly continuous state of panic. While the Veteran reported difficulty with activities of daily living, the Veteran still maintained a full-time job as a school teacher, which showed that he was able to function independently. Moreover, the Veteran reported at the VA examination that he had a good impulse control and no history of violence. While the Veteran did report stress at work and social functioning problems, he also reported that he maintained a good relationship with his wife. The Veteran's main argument is that he should be compensated at a higher rating for PTSD from the date of claim until November 16, 2010. The medical evidence simply does not support the Veteran's contention. Therefore, a higher rating is not warranted. The Board concludes his overall level of disability more nearly approximates that consistent with a 50 percent rating. The findings in the January 2007 VA examination report support this conclusion. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to an increased disability evaluation for PTSD, prior to November 16, 2010, must be denied. See 38 U.S.C.A §5107 (West 2002 & Supp. 2010). B. Rating Higher than 50 percent from November 17, 2010, forward In determining whether the Veteran is entitled to a rating higher than 50 percent since November 17, 2010, the Board has reviewed the November 2010 VA examination report. Based on this evidence, the Board finds that the Veteran is entitled to a higher disability rating of 70 percent, but no higher, during this time period at issue. The Veteran was afforded a VA examination on November 17, 2010. The Veteran reported that his symptoms of PTSD had significantly worsened in the last year, in that he was experiencing more nightmares and flashbacks. Additionally, he stated that his marital and family relationships were of poor quality, and he was socially isolated. However, the Veteran reported that he enjoyed meeting with others he served with. The Veteran did not have a history of suicide attempts or violence. Additionally, the Veteran stated that he continued to have problems with alcohol abuse and self medicating. Upon examination, the Veteran was noted to be appropriately dressed, cooperative, and friendly. His speech was unremarkable, and he had a full affect, and an anxious and depressed mood. The Veteran was found to be oriented to person, place, and time. His thought process was rambling, and his thought content had ruminations. The Veteran stated that he did not have delusions or hallucinations. Additionally, he understood the outcome of his behavior. The Veteran reported an increased number of flashbacks, panic attacks, and night sweats that disrupted his sleep. The examiner noted that he did not have inappropriate behavior. Additionally, the Veteran reported having at least three panic attacks per week. Furthermore, the Veteran's memory was found to be normal. The Veteran reported that he was a teacher and retired in May. Additionally, he stated that in the more recent years his work was impacted by his PTSD symptoms and the effects of drinking, such as absenteeism, being sick at work, and being less effective. The Veteran was diagnosed with PTSD, major depression, and alcohol dependence, and assigned a GAF score of 48. The Veteran's symptoms that worsened since his last examination included night sweats, nightmares, physiological arousal, secondary depression, etoh dependence and abuse, estrangement from his family, social isolation, and decreased quality of life. The examiner reported that the Veteran did not have total occupational and social impairment due to his PTSD symptoms. However, the examiner did note that the Veteran's PTSD symptoms resulted in deficiencies in judgment, thinking, family relations, work, and mood. The examiner concluded that it is clear from the examination that the Veteran's conditions were worsening. The record reflects that the Veteran continued to seek outpatient treatment for his PTSD at the VAMC. Additionally, the records show that the Veteran was receiving counseling and medication for his mental health condition. After a review of the evidence of record, the Board finds that the Veteran's PTSD symptoms have been found to display the criteria contemplated by a 70 percent rating under DC 9411: 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. 38 C.F.R. § 4.130, DC 9411. Additionally, the Veteran's GAF score has not fallen below 48, which is indicative of serious, but not total, occupational and social impairment. Accordingly, the Board finds that the Veteran's PTSD symptoms have not worsened to the extent that a 100 percent disability rating is warranted. 38 C.F.R. § 4.130, DC 9411. While the Veteran did show signs of an inability to perform activities of daily living and maintenance of personal hygiene, he did not exhibit other symptoms necessary to establish a 100 percent disability rating for PTSD. At no time during the appeals period has the Veteran been found to display total occupational and social impairment, due to such symptoms as grossly impaired thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; disorientation to time, place, or space; or memory loss for names of close relatives, own occupation, or own name. In this regard, the Board points out that the Veteran did not report any delusions or hallucinations at the November 2010 VA examination. Additionally, the VA examiner noted that the Veteran did not exhibit inappropriate behavior, and noted that the Veteran was oriented to time, place, and space. Moreover, the Veteran did not report any memory problems such as a loss of names of close relatives, own occupation, or own name. The VA examiner noted that the Veteran was cooperative, friendly, and appropriately dressed. While the Veteran reported that he had no friends and isolated himself at home, he still remained married and had a relationship with his wife. Additionally, while the Veteran reported problems at work, he still maintained a full-time job as a school teacher, until he retired in May 2010. Furthermore, at the VA examination the Veteran reported that he enjoyed meeting with fellow Veteran's he served with. Furthermore, the VA examiner noted that the Veteran did not have total occupational and social impairment due to his PTSD symptoms. While the Veteran reported suicidal thoughts, he stated that he did not have any intent or plan. Additionally, the Veteran reported that he did not have a history of violence. Therefore, he was not in persistent danger in hurting himself or others. Consequently, although not all of the enumerated symptoms recited for the 70 percent rating are shown, the Board nonetheless finds that the severity of the Veteran's PTSD symptoms and the significant effect of these symptoms on his social and work situation justify assigning a higher disability rating of 70 percent. Mauerhan v. Principi, 16 Vet. App. 436 (2002). All reasonable doubt has been resolved in favor of the Veteran in making this decision. The preponderance of the evidence is for the assignment of a higher 70 percent rating for the Veteran's PTSD, from November 17, 2010, forward. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Extraschedular Consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's PTSD are not shown to cause any impairment that is not already contemplated by the rating criteria, and the Board finds that the rating criteria reasonably describe his disability. For this reason, referral for consideration of an extraschedular rating is not warranted for this claim. ORDER Entitlement to an rating in excess of 50 percent prior to November 17, 2010, for the Veteran's PTSD, is denied,. Entitlement to an increased disability rating of 70 percent for the Veteran's PTSD is granted, effective November 17, 2010. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs