Citation Nr: 1237161 Decision Date: 10/26/12 Archive Date: 11/09/12 DOCKET NO. 10-24 016 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to an initial disability evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD James G. Reinhart, Counsel INTRODUCTION The Veteran served on active duty from June 2003 to March 2006. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. FINDINGS OF FACT The Veteran's PTSD does not result in more than occupational and social impairment with reduced reliability and productivity due to symptoms including, and similar to, impairment of memory, judgment, and abstract thinking, disturbance of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. CONCLUSION OF LAW The criteria for a disability rating higher than 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21,4.126, 4.130 Diagnostic Code 9411 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, 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. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For service-connection claims, this notice must address the downstream elements of disability rating and effective date. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Here, the claim that gave rise to this appeal was a claim of entitlement to service connection for PTSD received by the RO in May 2006. The VCAA duty to notify was satisfied by way of a letter sent to the Veteran in November 2006 that fully addressed all required notice elements and was sent prior to the initial RO decision in this matter. The letter informed the Veteran of what evidence was required to substantiate the claim, the Veteran's and VA's respective duties for obtaining evidence, and the evidence relevant to assignment of disability ratings and effective dates. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of service and other pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained service and VA treatment records and the Veteran has submitted private records. VA provided examinations in January 2007 and September 2009. Those examinations are adequate because reports from those examinations include detailed descriptions of the Veteran's disability, show that the examiners reviewed his claims file and considered the relevant history of his PTSD, and the examiners provided sufficient explanations for VA to weigh along with other evidence of record. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist under the VCAA. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Increased Rating The Veteran contends that he suffers from most of the symptoms listed under the criteria for a 70 percent disability rating and therefore he is entitled to a disability rating higher than the 50 percent rating that has been in effect since the day after the date that he was separated from active service. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. II.A. Increased Rating - Factual Background The Veteran's DD Form 214 documents that he had active service in Kuwait and Iraq in 2004 and 2005 and was awarded the combat action medal - indicative of engaging in combat with the enemy. An April 2005 post deployment health assessment documents the Veteran's reports that in the previous two weeks he felt down, depressed, or hopeless, and had little interest or pleasure in doing things. He also reported that in the past month he had nightmares about or thought about (when he did not want to) experiences that he found frightening, horrible, or upsetting. He reported that he was constantly on guard, watchful, or easily startled, and that he had concerns or thoughts that he may have serious conflicts with his spouse, family members, or close friends. Similar reports are found in a July 2005 post deployment health assessment. December 2005 service treatment records document that the Veteran was evaluated for increased irritability, thoughts of hurting others, and fear of losing control. May through November 2006 VA treatment notes document that the Veteran had difficulty sleeping and emotional difficulty. Clinical mental status examination in July 2006 found him alert and attentive, oriented times 3, and cooperative and reasonable. He had no unusual thought content, his grooming was appropriate, and his affect was congruent with his mood. He reported that he felt nervous and was prescribed medication for anxiety and depression. In January 2007, the Veteran underwent a VA compensation and pension (C&P) examination with regard to his PTSD. He reported that he slept approximately 8 hours per night, awakens by an alarm, and that his sleep is occasionally interrupted by sounds. The examiner stated that the Veteran did not spontaneously offer that he experienced nightmares or flashbacks. The Veteran reported that the presence of someone behind him, for example in line at a store, made him uncomfortable. Cognitive assessment included that he attended the examination casually dressed, well groomed, and in no acute distress. His responded articulately and clearly during the examination, his responses were goal directed, and he had a full range of affect. He showed no signs of cognitive impairment. The examiner stated that the Veteran was independent as to personal hygiene and all activities of daily living. He noted the Veteran's report that he disliked his service in Iraq to the extent that he occasionally thought of suicide. The examiner also stated that there was no history of hallucinations or delusions. In a conclusion section of the report, the examiner stated that the Veteran had, at some time, experienced his in-service stressor in the form of nightmares, and that it was as likely as not that he had some arousal and avoidance behavior related to PTSD. As to impairment, the examiner stated that his PTSD seemed to cause the Veteran some mild social impairment and some moderate anxiety and emotional impairment, but no occupational impairment. He diagnosed PTSD and assigned a Global Assessment of Functioning (GAF) score of 60. Of record is a Judgment of Divorce dated in July 2010. Relevant evidence includes comments and reports from the individual to which the Veteran was married prior to July 2010. The Board refers to her in the instant document as his spouse at the time or as his former spouse. A July 2008 Intake Assessment signed by a psychologist from Kalamazoo Psychology, LLC, documents the Veteran's report of periods of depression and anxiety, avoidance of crowds, and a tendency to drink too much in social situations. The Veteran's spouse at the time reported to the psychologist that at times the Veteran has a quick temper with their daughter. Mental status examination results included that the Veteran's appearance was neat, and that he was friendly and cooperative, and oriented times 3. His speech was appropriate, memory function was normal, affect was appropriate, motor activity was relaxed and at ease, and judgment was fair. He had no delusions, disorganized thinking, or hallucinations. As to evidence of depression, the Veteran reported that his appetite was normal, he had no sleep disturbance, his sex drive remained the same, there were no recent losses, and he had a high energy level. He had no suicidal or homicidal thoughts. The examiner noted that the Veteran attended technical school post-service and recently started a job with an automotive company. Assessment was that he had the following PTSD symptoms: anxiety, depression, irritability, sleep disturbance, social isolation, increased startle response, dislike of crowds, and hypervigilance. Also noted was that the Veteran had a habit of abusing alcohol to cope with his symptoms, but had recently refrained from drinking due to loss of control when drinking. The psychologist stated that his current GAF was 55 and his GAF during the past year was 57. VA conducted another C&P examination in September 2009. The examiner indicated review of the claims file and provided a narrative history of the evidence in the claims file including the Intake Assessment and the 2007 examination report, as well documenting as information obtained during interview with the Veteran. Symptoms reported were anxiety, lack of motivation, inability to sustain focus, nightmares, and memory problems. The Veteran's spouse at the time attended the examination with him and reported that he grinds his teeth during sleep, and grabs her and tells her to get down, apparently dreaming about his military experiences. Also noted was that the Veteran had been working since 2008. His spouse at the time reported that the Veteran had asked for a divorce several times and that his requests were on an irrational basis. She reported that he had difficulty in his relationships with her family. As to social relationships, the examiner noted that the Veteran was working 50 hours per week for an automotive company and that, according to the Veteran's spouse at the time, when he was not working the only places that he visited socially were bars. The Veteran expressed interest in automotive maintenance and the local college football team. He referred to an incident that occurred while he was living in another state and the Veteran commented that it might have been a suicide attempt. He reported that he was thinking of driving his truck off a cliff and drove up a mountain with this intention but then changed his mind. His spouse at the time commented that the Veteran's excessive drinking may represent an indirect suicide attempt. She also reported an incident in which he became angry and began throwing and damaging property in the home. Noted by the examiner was that there had been no incidents in which he acted aggressively toward his spouse, stepdaughter, or others. Also noted was that the Veteran was estranged for his own family. Next is the section of the report documenting results of the actual psychiatric examination. The Veteran arrived promptly and casually dressed for the examination and was cooperative with and attentive to the examiner. Psychomotor activity and speech were unremarkable. His affect was flat. As to mood, it was noted that despite his report of distress, the Veteran was responsive to humor and quite engaged in bantering about the local football team. As to his attention, he was able to do serial sevens but was unable to spell a word backwards and forwards. His spouse at the time commented that "he zones out a lot and just stares off into space. He takes a really long time to answer questions." He was oriented times 3, his thought process and content were unremarkable; he had no delusions. As to judgment, the examiner stated that the Veteran understands the outcome of behavior. As to insight, the examiner stated that he understands that he has a problem. The examiner reported that the Veteran had sleep impairment in that on most nights sleep latency is estimated to be about 15 minutes, that during the course of the night he awakens several times, and that he has distressing dreams about his military experiences. The Veteran reported that he has daily daytime sleepiness. His spouse at the time reported that the Veteran only gets 5 to 6 hours of sleep a night and wakes up a lot but does not realize it. The examiner stated that the Veteran did not have hallucinations or inappropriate behavior, and did not interpret proverbs appropriately. Also noted was that he had obsessive / ritualistic behavior, in that he is unusually attentive to the cleanliness of his truck and maintaining his tools. The examiner stated that what sounds like obsessiveness or preoccupation regarding his vehicles may also be present. Also noted was that he had panic attacks when around a crowd. There was some suicidal ideation, he had fair impulse control in that there was some impulsive spending. There were no episodes of violence, he had no problems with the activities of daily living, and he had the ability to maintain minimum personal hygiene. Remote memory was normal. Recent and immediate memory were found to be mildly impaired. In this regard, the Veteran reported that he could not remember anything and that his spouse at the time was his memory. She stated that he had difficulty recalling information and experiences since his return from Iraq. Also included in the report were results of psychiatric testing. The examiner commented that the credibility of his reports on the Mississippi Scale for Combat Related PTSD (MMPI PTSD Subscales) was dubious. He noted that the Veteran completed the Beck Depression Inventory endorsing some severe, some moderate, and some mild symptoms. The examiner commented as follows: The complete MMPI-2 was administered and the profile that results if (sic) psychometrically invalid on the basis of several scales and components. It is important to emphasize that the veteran did carefully attend to item content and entered his responses in a deliberate and thoughtful manner. His VRIN T-score of 46 (raw 4) provides objective evidence of this. In other words, the psychometric invalidity of the profile is not based on random or careless responding. Rather, the veteran tended to portray himself in the most negative light possible. On the Dissimulation Index (F-K) he obtains a remarkable score of 35. This value is more than twice the value (17) recommended to determine a profile is invalid due to exaggeration. The veteran's a raw score of 42 on the Infrequency (F) scale, which contains only 60 items. This translates into a score that is more than 7 standard deviations beyond the mean. Further corroborative evidence of invalidity is the vet's T-score of 120 on the Infrequency-Psychopathology (Fp) scale. The examiner concluded that the psychological test results are probably invalid. It was noted that the Veteran works full time and had for the past 1 to 2 years. As to time lost from work in the last 12-month period, the Veteran reported that he lost 5 weeks and that "I just didn't feel like going. One time I was elected to do the team meeting and I can't be in front of crowds, even if it's people I work with." Some of the absences from work were noted to be related to his the illness and hospitalization of hi spouse at the time. As to problems related to occupational functioning the examiner listed increased tardiness and absenteeism and poor social interaction. The examiner diagnosed PTSD, moderate, and assigned a GAF score of 50. He stated that there were no comorbidities but that the Veteran "does appear to be embellishing the presentation of symptoms." The examiner then provided "yes" and "no" answers to statements as to the effect of PTSD on the Veteran's social and occupational functioning. These statements are identical to sentences found in VA's rating criteria for mental disorders. The examiner provided "no" answers to all statements other than "Is there reduced reliability and productivity due to PTSD symptoms?" He provided a "yes" response to that statement and explained as follows: It may be difficult to believe / accept everything this veteran says about himself. That is, the symptoms and complaints he offers span the spectrum from neurotic to characterologic to even psychotic. His style of embellishment may be a reflection of his emotional vulnerability and his unstable and ineffective psychological defenses. It seems in certain ways that he experiences life in an exaggerated fashion because he is not able to reliably ward off threat and work through his conflicts and worries. He expresses himself in an exaggerated manner because of his difficulty in modulating his emotional experiences. The dependency that he exhibits is not really of the typical "neurotic" variety but rather may be associated with his need to rely on others given realistic problems and limitations in coping with them. In September 2009, the RO received statements authored by the Veteran and by his spouse at the time. He reported that he his mood, work, and family relations are impaired by his PTSD and that this impairment interferes with routine activities. He reported that he is in near continuous depression, does not like to participate in family functions and had asked his spouse for a divorce, packed his things, and left the house 3 times. He stated that he has problems at work in that he does not get along with his co-workers, has disputes with them on a regular basis, and keeps to himself. He reported that he has impaired impulse control such as unprovoked irritability, describing this in the following manner: "I often provoke my spouse into arguments and then leave without resolving these issues." His spouse at the time essentially reported what the Veteran reported. She also stated that the Veteran tended to not pay attention, picked fights with her, was irritable, did not get along with people at work, spoke of his job in an angry manner, and obsessed about his vehicles. She stated that the Veteran told her of times that he wanted to commit suicide, and told her he suffered from anxiety and depression. She reported that the Veteran goes few places with her, and does not like being around crowds. She reported that the Veteran does not have any friends and the only places that he likes to go are bars. In his May 2010 substantive appeal, the Veteran reported that he was going through a divorce which he anticipated would be final the following month. He reported that this was his second divorce since returning from Iraq. He reported that he recently lost his job at the automotive establishment because it closed. He also reported that he had difficulty with his co-workers and that his supervisor allowed him a little leeway because he showed up on time, did his job, and was a combat veteran. He also reported that he had a history of suicidal ideation and has thought about suicide from time to time. He expressed his opinion that he has all of the symptoms listed in the criteria for a 70 percent disability rating other than an inability to maintain personal hygiene and appearance. II.B. Increased Rating - Analysis In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1 , 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 . In cases involving disagreement with the initial rating assigned, separate ratings may be assigned for different periods of time on appeal if the facts show that different ratings are warranted; a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). Thus, the Board has considered the propriety of staged ratings in assessing the Veteran's service-connected disability. The criteria for evaluating disability due to service-connected mental disorders is specified by the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where 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; intermittently illogical obscure, or irrelevant speech; 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 is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. That portion of VA's Schedule for Rating Disabilities that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2011). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health - illness. Higher scores correspond to better functioning of the individual. GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (4th. ed., 1994). GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. The preponderance of evidence is against a finding that disability due to the Veteran's PTSD has approximated the schedular criteria for a rating higher than 50 percent during any period of time from the date that he was separated from active service to the present. Although he has reported that he has all but one of the symptoms listed for the 70 percent criteria, his reports must be weighed against the other evidence of record, most notably the expert evidence from the examination reports. The Board finds that the preponderance of evidence is contrary to this assertion. First, the Board determines that the examiner's finding expressed in the September 2009 examination report with regard to the Veteran's reports tend to show that the weight afforded to the Veteran's reported symptoms must be reduced. Based upon well explained psychological test results, that examiner determined that the Veteran was embellishing his symptoms. Also leading the Board to the conclusion that the Veteran's report of symptoms are to be afforded reduced weight is his and his former spouse's descriptions of symptoms listed in the criteria for a 70 percent rating. For example, the Veteran reports that he has unprovoked irritability. However, his description of that symptom - that he often provoked his spouse and then left the house without resolving the issue - is not consistent with the symptom. What the Veteran alleges is that he provokes his spouse, not that he suffers from unprovoked irritability. Furthermore, the examiner stated that there were no violent episodes. Although the Veteran's spouse reported that he damaged property in the home, there is no indication that such incident resulted from unprovoked irritability. The only other report of impaired impulse control was his spending habits. The Board finds that the report by his former spouse that he spends money on items that he does not need, is insufficient to show that he has impaired impulse control to the degree or with impairment consistent with the symptoms described for a 70 percent rating. He also points to suicidal ideation as a basis for assigning a 70 percent rating. However, the schedular criteria for a70 percent rating refers to occupational and social impairment with deficiencies in most areas due to such symptoms as suicidal ideation, not merely the presence of such ideation. The evidence does not show that his suicidal ideation has ever resulted in deficiencies in most areas. Furthermore, his and his former spouse's reports of suicidal ideation tend to show that there is no impairment resulting from such ideation. He refers to one incident where he drove up a mountain contemplating suicide but changed his mind as he drove. Similarly, his spouse theorized that his excessive drinking may be considered an attempt at suicide. The reports of his suicidal ideation and the lack of any showing as to how this symptom results in impairment in most areas tends to show that this symptom does not result in the impairment specified under the 70 percent criteria. Also considered by the Board are the reports of obsessional or ritualistic behavior. Again, the behavior described and the impact on his occupational and social functioning is not shown to be consistent with a rating higher than 50 percent. The behavior described involved attention to his vehicles and tools and a preoccupation with cleanliness. There is no showing that this causes any interference with routine activities. Furthermore, the Veteran has always been found to be oriented in three spheres - there is no spatial orientation shown. Although he reported difficulties at work at the automotive company, his adaptation to what he perceived as stressful does not appear to have been difficult. He essentially avoided co-workers. Although he has alleged that he has near continuous panic or depression, the opposite is shown by the examination reports. In this regard, the examiner commented that although he reported distress he responded well to humor and bantered about football. As to panic, by his own account this occurs in situations involving crowds and / or when someone is behind him in a line in a store. This is evidence that his panic is not near continuous. His speech has always been found to be unremarkable as to content and form. The evidence tends to show that he does have the ability to establish and maintain effective relationships. This is shown by his report of his employment at the automotive company in that he was able to establish and maintain an effective relationship with his supervisor who, according to the Veteran, made concessions for him at work. The Board does not find any other symptoms suffered by the Veteran that are similar in kind or degree to those listed under the criteria for a 70 percent rating. Also supporting a finding that, at most, the Veteran meets the criteria for a 50 percent rating, are the GAF scores assigned over the course of his appeal. His disability picture does closely approximate the criteria for a 50 percent rating. In this regard he has been shown to have disturbance of mood and difficulty establishing and maintaining effective work and social relationships and his affects has been found to be flat. The effect of these symptoms is in line with no more than occupational and social impairment with reduced reliability and productivity. Finally, the GAF scores prior to September 2009 were all in the 51 to 60 range, indicating moderate symptoms, which the Board finds consistent with a 50 percent rating. While a GAF of 50 was assigned in the September 2009 examination, that value is at the very edge of serious symptoms. Given the other findings, the Board finds that this score does not shift the weight of the evidence to the extent that the criteria for a rating higher than 50 percent is approximated. The detailed discussion of symptoms reported by the Veteran and his former spouse and the examination findings are in agreement with the expert's determination in the September 2009 report as to the extent of impairment caused by the Veteran's PTSD. For these reasons, the Board finds that the preponderance of evidence is against assigning a schedular rating higher than 50 percent for any period of time from the date that the Veteran was separated from active service to the present. Nor does the Board find that referral for a rating outside of the schedule is warranted. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2011). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. Id. Extraschedular consideration involves a three element analysis. Thun v. Peake, 22 Vet. App. 111 (2008); Anderson v. Shinseki, 22 Vet. App. 423, 427 (holding that "steps" listed in Thun are indeed elements that must be met). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Thun, 22 Vet. App. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. Here, the schedular criteria consist of a non-exhaustive list of representative symptoms. The Veteran's reported symptoms are all contained in the representative symptoms. The schedule also provides for greater disability than that shown by the evidence in this case. For example, a 100 percent rating can be assigned if the claimant has total social and occupational impairment; a degree of disability not present in this case. Therefore, the first Thun element is not met. That alone is sufficient to decline to remand this matter for consideration by the Under Secretary for Benefits or the Director of the Compensation and Pension Service. As a matter of completeness, the Board finds that there are no related factors shown to be present in this case, including no showing of hospitalization or marked interference with employment and no factors similar in kind or degree to frequent hospitalization or marked interference with employment. The Board has not ignored the Veteran's reports regarding his job at the automotive company. But, the amount of work missed and the other difficulties described do not rise to the level of marked interference with employment. In this regard, it is noted that the degrees of disability found in the rating schedule 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. See 38 C.F.R. § 4.1. For the reasons stated above, the Board finds that the preponderance of the evidence is against assigning a higher schedular rating for any period of time from the day after the date the Veteran was separated from active service to the present and is (CONTINUED ON NEXT PAGE) against remanding the matter for referral for extraschedular consideration. Hence, the appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2011); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a disability evaluation in excess of 50 percent for PTSD is denied. ____________________________________________ FRANK J. FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs