Citation Nr: 1127333 Decision Date: 07/21/11 Archive Date: 07/29/11 DOCKET NO. 07-24 798 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial increased disability rating in excess of 10 percent for posttraumatic stress disorder (PTSD) from November 15, 2005, to April 30, 2010, and a rating in excess of 30 percent from May 1, 2010, forward. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1970 to May 1972. This case is before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which granted service connection for PTSD and assigned a 10 percent disability rating, effective November 15, 2005. The Board notes that, while the Veteran filed his claim with the RO in Atlanta, Georgia, the rating decision was issued by the Columbia, South Carolina RO. The Veteran filed a Notice of Disagreement with his rating and subsequently perfected an appeal. Subsequently, in a May 2011 rating decision, the Appeals Management Center (AMC) increased the Veteran's disability rating for PTSD to 30 percent, effective May 1, 2010. The Veteran was afforded a Travel Board hearing before the undersigned Veterans Law Judge in December 2009, at the St. Petersburg, Florida RO (who now has jurisdiction of the Veteran's claims' folder). A written transcript of this hearing was prepared and incorporated into the evidence of record. In February 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 15, 2005, to April 30, 2010, the Veteran's PTSD was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). 2. From May 1, 2010, forward, the Veteran's PTSD has been productive of occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating of 30 percent, but no higher, for PTSD from November 15, 2005, to April 30, 2010, have 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 50 percent, but no higher, for PTSD from May 1, 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 U.S.C.A. §§ 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). The Veteran's claim of increased disability rating for PTSD arises from his disagreement with the initial evaluation assigned following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required for this claim. 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 VA and private medical records, and providing the Veteran with VA examinations in January 2006 and May 2010. Additionally, the Veteran has not indicated that he has received additional treatment for his service-connected PTSD. The Board thus concludes that there are no additional 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. Initial Increased Ratings The Veteran and his representative contend, in substance, that the Veteran's PTSD is more disabling than currently evaluated. It is noted that service connection was established for PTSD in the currently appealed April 2006 rating decision, and a 10 percent disability rating was assigned, effective November 15, 2005. Subsequently, in a May 2011 rating decision, the AMC increased the Veteran's disability rating for PTSD to 30 percent, effective May 1, 2010. The Board will address whether a higher rating or ratings should have been granted for any of these time periods. 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 2008); 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). 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). In Fenderson v. West, 12 Vet. App 119 (1999), the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case (such as this one) in which the Veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a) (West 2002). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b) (West 2002). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. The Veteran is currently assigned a 30 percent 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 10 percent evaluation is provided for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent evaluation is provided for 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). 38 C.F.R. § 4.130 (2010), DC 9411 (2010). 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). 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 10 percent from November 15, 2005, to April 30, 2010 The evidence of record for consideration concerning this initial time period includes the November 2005 and December 2005 private psychiatric treatment reports, and the January 2006 VA examination report. Based on this evidence, the Board finds that the Veteran is entitled to a higher initial disability rating of 30 percent, but no higher, during the initial time period at issue. The record contains November 2005 and December 2005 private psychiatric treatment reports. At the November 2005 appointment, the Veteran stated that he could not let go of his war moments, and that it was like it happened yesterday. He reported that his self-confidence was destroyed on his return from war, and that the events of 9-11 brought it all back. The Veteran reported that he was living with his girlfriend and her son. The doctor noted that the Veteran's affect was worried and nervous. Additionally, the doctor reported that the Veteran's behavior, thought content, thought process, memory, abstractions, cognitive ability, judgment, and insight were all within normal limits. The Veteran also denied any suicidal ideations. He reported having visual flashbacks, a decrease in concentration, insomnia, and a history of irritability. The doctor noted that the Veteran was psychologically impaired, but was still able to work. A December 2005 follow-up appointment noted that the Veteran was experiencing mild symptoms associated with decreased energy, family/relationships, irritability/mood instability, work and school, and substance abuse. Additionally, the Veteran was noted to have moderate symptoms that included anxiety, depressed mood, inattention, sleep disturbances, and panic attacks. The doctor diagnosed the Veteran with mild to moderate A.D.D., major depression, and PTSD, and assigned a global assessment of functioning (GAF) score of 65. The Veteran was then prescribed psychotropic medication for his mental health conditions. The Veteran was afforded a VA examination for PTSD in January 2006. The Veteran reported that since returning from Vietnam he suffered from nightmares, trouble sleeping, hyperawareness, depression, and problems controlling his anger. Further, the Veteran stated that he had intense suicidal thoughts, and was hospitalized one time in a mental hospital for six months in the winter of 1979 to 1980. Additionally, the Veteran believed that his mental condition was impairing his ability to interact socially, and had contributed to both of his divorces, as well as causing him to lose jobs. He reported that he was no longer receiving psychiatric treatment because he believed it was not helping, and reported that after leaving service, he worked at a number of jobs in various industries. He stated that he held his longest job for seven years, where his relationships with his supervisor and coworkers were poor. Specifically, the Veteran stated that he had trouble getting along with people at work, and was frequently terminated for fighting, arguing, and being absent. Furthermore, the Veteran reported having a poor relationship with his siblings. While he stated he was previously divorced, the Veteran also reported that he was currently living with his girlfriend, and stated that his relationship with his children was fair. Upon examination, the Veteran's orientation was within normal limits, and his appearance, hygiene, thought process, and behavior were appropriate. The examiner noted that the Veteran's affect and mood were abnormal, with a flattened affect. Moreover, the Veteran's communication was abnormal with findings of poor eye contact. However, his speech was within normal limits. Furthermore, panic attacks, hallucinations, delusions, and obsessional rituals were not reported. The Veteran's judgment was not impaired, and his abstract thinking and memory were within normal limits. Lastly, the Veteran did not report suicidal or homicidal ideations. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 70. The examiner restated that Veteran's disturbances were consistent with a diagnosis of PTSD. Additionally, the examiner noted that the Veteran's disturbances caused distress or impairment in social, occupational, or other areas of functioning. The examiner noted that the Veteran's disease was chronic, with duration of symptoms of three months or more, and noted that the Veteran was capable of managing benefit payments, and did not have difficulty performing activities of daily living. Additionally, the examiner stated that the Veteran had difficulty establishing and maintaining effective work and social relationships because he did not trust others, and preferred to be alone. Furthermore, he had no difficulty understanding commands. Lastly, the examiner noted that the Veteran appeared to pose no threat of persistent danger or injury to him or others. After a review of the evidence of record, the Board finds that as of November 15, 2005, the Veteran's PTSD symptoms have been found to display the criteria contemplated by a 30 percent rating under DC 9411: 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). 38 C.F.R. § 4.130 (2010). The Board notes that the Veteran's GAF scores did not fall below 60, which illustrates 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. However, 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 flattened affect and difficulty in establishing effective work relationships, while still maintaining relationships with his children and girlfriend, correspond with GAF scores of 65 to 70. At no time since November 15, 2005 up to April 30, 2010, has the Veteran been found to display 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. While the Veteran did show signs of flattened affect and difficulty in forming relationships at work, he did not exhibit other symptoms necessary to establish a 50 percent disability rating for PTSD. The Veteran's private psychiatrist and the January 2006 VA examiner noted that the Veteran's judgment was not impaired, and his abstract thinking and memory were within normal limits. Additionally, the Veteran's orientation and speech were found to be within normal limits. The examiner noted that the Veteran had no difficulty in understanding commands, and while the Veteran reported trouble with establishing work relationships, he also stated that he lived with his girlfriend and had relationships with his children, showing that he was able to establish and maintain effective relationships. Lastly, the Veteran reported at the VA examination that he did not experience panic attacks. While the Veteran's December 2005 private treatment record shows that he reported panic attacks, he did not state that he was experiencing them more than once a week. In sum, the Board finds that the evidence of record shows that the Veteran's symptoms have warranted a disability rating of 30 percent, but no higher. Hart v. Mansfield, 21 Vet. App. 505 (2007). 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 30 percent disability rating for the Veteran's PTSD, from November 15, 2005 to April 30, 2010. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Rating Higher than 30 percent from May 1, 2010, forward In determining whether the Veteran is entitled to a rating higher than 30 percent since May 1, 2010, the Board has reviewed the December 2009 Travel Board hearing transcript and the May 2010 VA examination report. Based on this evidence, the Board finds that the Veteran is entitled to a higher initial disability rating of 50 percent, but no higher, during this time period at issue. The Veteran was afforded a Travel Board hearing in December 2009, during which he reported that he could not sustain any relationships in his life, except for his children. The Veteran testified that his children grew up living with him, and distracted him from his thoughts. Additionally, he reported that his relationship ended with his girlfriend because he was told he could not connect emotionally, was detached, and was scary. Furthermore, he stated that he had very few friends, who were mostly co-workers. Moreover, he reported problems with anger and anxiety. The Veteran was afforded a VA examination in May 2010, during which he reported that he was divorced and not currently in a relationship. He stated that he was in a relationship that ended about a year and a half ago because she said that he was emotionally unavailable and his hyperawareness scared her. Furthermore, he noted that it scared her that he kept a bat at the front door and slept with a machete. The Veteran also reported that he had children that he got along with, but typically only communicated with them through email. Additionally, the Veteran reported that he had a non-existent social life, adding that his coworkers would invite him out, but he would not go very often because he was not comfortable in crowds. Moreover, he stated that he did not have any close friends. Upon examination, the Veteran was found to be appropriately and casually dressed, and clean. Additionally, his speech was unremarkable, and his attitude was cooperative and guarded. Furthermore, his affect was noted to be blunted, and mood dysphoric. He was also found to be oriented to all spheres. His thought process and content were unremarkable, and his judgment was not impaired. He reported problems sleeping, including nightmares. Furthermore, the Veteran was not noted to have inappropriate behavior. The Veteran reported that he had obsessional rituals, which included checking and rechecking doors. Additionally, he reported that he had no panic attacks. However, he reported that he was having issues with work that caused him to become more anxious with increased breathing, where he wanted to run out of work. The Veteran also stated that he had suicidal ideations, but no plans or intent. The Veteran's impulse control was stated as fair. Moreover, he was noted to maintain his personal hygiene, and the examiner also reported that the Veteran had no problems with activities of daily living. Additionally, the Veteran was noted to have normal memory. However, the Veteran reported that he had problems with his memory when he was under stress. The examiner noted that the Veteran's PTSD symptoms were chronic, daily, moderate symptoms that interfered with his social functioning and relationships. Additionally, the examiner noted that the Veteran was capable of managing his financial affairs. The Veteran reported that he worked fulltime as a planner for the county government for two to five years. However, he reported missing two to three weeks of work in the last 12 month period due to migraines and feeling too angry to be at work. Lastly, he stated that he can last about three years on a job and then starts to have interpersonal problems. After a review of the evidence of record, the Board finds that as of May 1, 2010, the Veteran's PTSD symptoms have been found to display 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 only GAF score of record for this time period was noted by the May 2010 VA examination above. The Veteran's GAF score was 55, 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 again 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 issues with establishing personal and work relationships, correspond with a GAF score of 55. 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: 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. While the Veteran did report suicidal ideations and obsessional rituals, 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 process and content were unremarkable at the May 2010 VA examination. Additionally, the Veteran was reported to be oriented in all spheres, and his appearance was clean, casual, and appropriately dressed. The examiner also noted that the Veteran did not report hallucinations or delusions. There was also no indication that the Veteran experienced panic attacks where he was in a nearly continuous state of panic. The VA examiner indicated that the Veteran was able to function independently, and had no problem with activities of daily living. While the Board notes that the Veteran reported that he had problems with irritability, the record is devoid of evidence indicating that the Veteran has had any periods of violence or any episodes of active aggression. While the Veteran reported stress at work and a lack of social and working relationships, he still maintained a relationship with his children, and stated that they got along well. Additionally, at the Veteran's hearing, he reported that he maintained a few friendships with coworkers. Therefore, the Veteran did not display an inability to maintain effective relationships. Consequently, although not all of the enumerated symptoms recited for the 50 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 50 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 50 percent rating for the Veteran's PTSD, from May 1, 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 initial increased disability rating of 30 percent for PTSD from November 15, 2005, to April 30, 2010, is granted. Entitlement to an initial increased disability rating of 50 percent for PTSD from May 1, 2010, forward, is granted. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs