Citation Nr: 1300587 Decision Date: 01/08/13 Archive Date: 01/16/13 DOCKET NO. 09-34 940 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Evaluation of posttraumatic stress disorder (PTSD) and major depressive disorder, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran had active service from January 1968 to August 1969, from June 1980 to March 1992, and from October 2001 to March 2008. This matter comes before the Board of Veterans' Appeals (Board) from a June 2008 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Salt Lake City, Utah, as part of the Benefits Delivery at Discharge (BDD) program. The purpose of the BDD program is to help ensure a smooth transition from military to civilian status by allowing service members to file pre-discharge claims for disability compensation with VA. Jurisdiction of the case was subsequently transferred to the RO in Denver, Colorado. The Veteran was previously awarded service connection for PTSD with dysthymic disorder, which was evaluated as 10 percent disabling, in a March 1994 rating decision by the RO in Denver, Colorado. However, his compensation benefits were discontinued when he returned to active duty from October 2001 to March 2008. In the rating decision on appeal, the Veteran's evaluation of PTSD and major depressive disorder was reinstated following his retirement, and the RO in Salt Lake City, Utah, awarded an evaluation of 30 percent, effective on April 1, 2008. The Veteran appealed the assigned evaluation. In a July 2009 rating decision, the RO in Denver, Colorado, granted an increased evaluation of 50 percent for PTSD and major depressive disorder, effective on April 1, 2008. The Veteran is presumed to seek the maximum available benefit; therefore, regardless of the increased evaluations granted during the pendency of the appeal, the issues remain before the Board on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). During the pendency of the appeal, in correspondence dated in July 2012, the Veteran withdrew his appeal on the issues of entitlement to initial compensable evaluations for cataracts and for a bilateral hearing loss disability. He indicated that he was not satisfied with the decisions included in the June 2012 Supplemental Statement of the Case (SSOC); however, he stated, "I however (sic) withdrawal (sic) my appeal on cataracts and on bilateral hearing loss." Therefore, although initially appealed, these issues are no longer in appellate status. 38 C.F.R. § 20.204(c) (2012); see also Hanson v. Brown, 9 Vet. App. 29 (1996) (when a claim is withdrawn, it ceases to exist; it is no longer pending, and it is not viable). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. FINDINGS OF FACT PTSD is manifested by deficiencies in the areas of thinking, family relations and mood. CONCLUSION OF LAW PTSD is 70 percent disabling. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130; Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial disability-rating and effective-date elements of a service connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that the Veteran is challenging the disability evaluation assigned following a reinitiation of his compensation benefits for PTSD following a period of activation. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-191. In a November 2007 pre-discharge letter, the RO notified the Veteran of the evidence needed to substantiate his service connection claims as part of the BDD program. He was also notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claims. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In connection with the current appeal, available service and private treatment records have been obtained. The Board notes that the Veteran has been afforded appropriate and adequate VA examinations as they reflects a pertinent medical history, review of the documented medical history, clinical findings, a diagnosis, and opinions supported by medical rationale. During the hearing, the Veterans Law Judge clarified the issues, explained the concept of a rating claim and explored the extent of the impairment. Such actions supplement VCAA and exceed any requirement under 38 C.F.R. § 3.103 (if applicable). For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim. The evidence of record provides sufficient information to adequately evaluate the claim, and the Board is not aware of the existence of any additional relevant evidence which has not been obtained. No further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). Accordingly, the Board will address the merits of the claim. Laws and Regulations Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, entitlement to compensation has already been established and increases in the disability ratings are at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service- connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Board finds that the Veteran's disability has not significantly changed since the Veteran's retirement from service and that a uniform rating is warranted. The Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C.A. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). The Veteran's PTSD is evaluated pursuant 38 C.F.R. § 4.130 Diagnostic Code 9411, and is subject to the criteria listed under the General Rating Formula for Mental Disorders. The General Rating Formula provides 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment or abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for 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 evaluation is indicated 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. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. In assessing the evidence of record, it is important to note that the GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 31 to 40 is assigned where there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Id. A score of 41 to 50 is assigned where 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. A score of 51 to 60 is assigned where there are 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, conflict with peers or co- workers). Id. A score of 61 to 70 is indicated where 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 generally functioning pretty well, has some meaningful interpersonal relationships. Id. Factual Background and Analysis The Veteran has appealed the denial of a rating higher than 50 percent disabling for PTSD. The current rating contemplates occupational and social impairment with reduced reliability and productivity. To warrant a higher rating, the evidence must approximate occupational and social impairment with deficiencies in most areas. See 38 C.F.R. § 4.7. Based on the evidence presented, the Board finds that a higher rating is warranted as the Veteran's symptoms are more characteristic of a disability picture that is contemplated by a 70 percent rating than that contemplated by a 50 percent rating under Diagnostic Code 9411. A majority of the type of criteria contemplated for a 70 percent rating under Code 9411 have been demonstrated. The Veteran was afforded a VA-sponsored QTC examination in December 2007, before his retirement. During the examination, the Veteran reported that he had not received treatment for his PTSD within the past year and he had not been admitted to the hospital or made any emergency room visits for psychiatric reasons. He indicated that he had good relationships with his parents, siblings, and children. He was divorced and did not have a significant other. He acknowledged that he did not have a civilian job to return to after he was activated over five years ago and he left his employment as an assembly person to return to active duty service. According to the examiner, the Veteran described persistent, recurrent recollections and dreams of his Vietnam service. He reported feelings of intense distress upon exposure to the violence in his neighborhood and stated that he slept with weapons available and within his reach. He indicated that he avoided firework displays, hunting shows, loud people, military celebrations, and significant activities like farewell parties. He related that he had a persistent feeling of detachment or estrangement from others and that he isolated himself at family get togethers. He described a moderately constricted affect, persistent irritability or outbursts of anger, an exaggerated startle response, difficulty concentrating, and persistent hypervigilance. He also reported that he had difficulty falling or staying asleep and he averaged three hours of sleep per night with occasional naps after work. On mental status examination, the examiner noted the Veteran's orientation was within normal limits. His appearance, hygiene, and behavior were appropriate. His affect and mood were abnormal with a near-continuous depressed mood. He demonstrated a flattened affect and described impaired impulse control, reporting that he struck people in the past. He noted that he had near-continuous panic attacks due to his impending retirement. He stated that he obsessed that he would be become homeless after retiring from the military. He described suspiciousness and stated that he scanned the areas around him and looked for avenues of escape. He described occasional delusions. The examiner noted there were no delusions or hallucinations observed on examination; however, he noted the presence of obsessional rituals, such as scanning the room for danger, which were not severe enough to interfere with routine activities. The examiner noted that the Veteran's thought processes were appropriate; his judgment was not impaired; and abstract thinking was normal. He noted that the Veteran's memory was moderately impaired, as he had difficulty with the retention of highly learned material, forgot to complete tasks, and he was unable to recall events and activities that he participated in with his brothers. Suicidal and homicidal ideation were absent; however, the Veteran reported that he had thoughts of hurting the man who married his ex-wife and was hassling his children. The examiner opined that the Veteran occasionally had some interference in performing activities of daily living because he forgot things at home that he needed during the day. The examiner related that the Veteran's current psychiatric symptoms caused occupational and social impairment with an occasional decrease in work efficiency and intermittent inability to perform occupational tasks, although he generally functioned satisfactorily with routine behavior, self-care, and normal conversation. He opined that the Veteran appeared to pose no threat of persistent danger or injury to himself or others. He assigned a GAF score of 60. In a September 2008 VA primary care treatment note, the Veteran denied auditory or visual hallucinations. He acknowledged some suicidal ideation, but indicated that he did not have a plan. In an October 2008 VA mental health note, the Veteran met with a licensed social worker for individual psychotherapy. During the session, the Veteran reported that he felt like he was "getting dementia... early [A]lzheimers," and he stated that he was unable to remember people or to do things "like feed [his] dog." He indicated that he left notes for himself all over his house to remind himself to do things. He related that he had significant problems sleeping. He worked the night shift and slept during the day. He also reported that he struggled with ongoing irritability and a short temper. Mental examination revealed the Veteran was oriented to person, place, and time, and he denied suicidal or homicidal ideation. The social worker noted that the Veteran "seem[ed] to be experiencing an exacerbation of his symptoms of PTSD (irritability, short temper, problems with sleep)." During a November 2008 VA mental health individual psychotherapy session, the Veteran reported that he continued to struggle with sleep due to his work schedule. The licensed social worker noted that the Veteran was oriented to person, place, and time, and he denied suicidal or homicidal ideation. In a December 2008 VA mental health medication management note, the authoring psychiatrist noted that the Veteran presented with problems of increased hypervigilance and hyperarousal since his retirement. He noted the Veteran was avoidant, irritable, and depressed. The Veteran indicated that he had difficulty sleeping and he had intense nightmares when he slept. He stated that he was often tired and unable to focus well at work. He complained of a poor memory and indicated that he was unable to remember names, he forgot where he put things, and he left notes to himself throughout his home. He stated that he liked to be alert and ready and he kept guns in his house. He indicated that he was unable to participate in activities that he used to enjoy, like running, due to poor motivation and decreased energy. The psychiatrist noted that the Veteran was oriented to person, place, and time. His attention was good, recent and remote memory were grossly intact, his fund of knowledge was good, and his insight and judgment were intact. A GAF score of 42 was assigned. The Veteran was afforded a VA examination in June 2009. During the examination, the Veteran reported that he worked for a company that serviced trains and he produced air conditioning units. He indicated that he last worked the graveyard shift in April 2008. He related that he worked from approximately 7:30 p.m. to 6:00 a.m., four days per week, plus some overtime. He stated that he slept approximately five hours and tried to rest during the day to prepare for work. He indicated that most of his friends were deceased and he was divorced. The Veteran described hyperarousal, reexperiencing symptoms, and avoidance behaviors. He had frequent disturbing dreams which caused him a great deal of anxiety. He complained of an increased startle response and hypervigilance. He indicated that he kept dogs and weapons, including a baseball bat, a sword, an ax, and firearms, in his home to increase his feeing of safety. He described tachycardia, shortness of breath with palpitations, and nervousness, and stated that it took some effort to try to calm himself. He indicated that he had intermittent problems with his temper, including a recent problem when he threatened a coworker who startled him on the job. He related that he had problems with easy frustration and poor patience. He stated that he tried to avoid confrontation; crowded, busy areas; intimate relationships; social activities; and discussing or focusing on his military experiences. The Veteran indicated that he had a history of intermittent suicidal ideation; however, he did not believe that he would act on his suicidal thoughts. He denied ever planning or intending to hurt himself. He denied auditory or visual hallucinations. The examiner noted that the Veteran's energy, interest, and motivation levels were fair. The Veteran indicated that he was able to mobilize himself to do various things and get to work. The Veteran noted some problems with his short-term memory and concentration. He indicated that he often felt "forgetful," and he described mistakenly locking himself out of his house on several occasions, forgetting his dog in the car on a hot day, and leaving the water running in the sink when he left his home. The examiner noted that the Veteran was casually dressed, generally polite, and cooperative. His mood was dysphoric and his affect was "restricted to the point of being almost flat." The examiner noted that the Veteran had some "noticeable cognitive changes," which were "suggestive of the onset of a dementia process with unknown etiology" and was "likely unrelated to his [PTSD]." He noted that there was some worsening of the Veteran's overall condition due to his cognitive symptoms; however, his PTSD symptoms were "fairly stable" and "continuous." He noted that the Veteran's thought processes and communication were impaired by difficulties with short-term memory and concentration. His social functioning was impaired by his high level of anxiety due to PTSD; however, he was employable from a psychiatric standpoint. The examiner opined that the Veteran was "best employed in areas in which he has little or no contact with the public and loose supervision, due to his high level of anxiety and frequency of panic symptoms." The examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity due to symptoms of flattened affect, panic symptoms more than once per week, difficulty with complex commands, impairment of short-term and long-term memory, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A GAF score of 55 was assigned. The Veteran was afforded another VA examination in May 2012. During the examination, the Veteran reported that he rarely had contact with his adult children. He spent his days fixing up his old house, fishing, painting, and making art. He denied difficulty completing activities of daily living. He indicated that he was dating and stated that his social life was "not bad." The Veteran reported that he had guns and a cleaver near his bed and he kept weapons near his front door because he slept better with weapons in close proximity. He had intrusive thoughts provoked by cooking smells and he felt angry and irritable when he drove. He denied any physical aggression. He indicated that he was jumpy and easily startled. He stated that he avoided watching war movies, crowds, loud noises, busy places, and thinking about his war experiences. He stated that he carried a compass so that he "always knows the way home." The Veteran related that he had suicidal thoughts and plans that included killing himself with a gun. He stated that he had no intention of acting on these thoughts because he was a Catholic and he did not "want to go to hell." He denied homicidal ideation. The examiner reported that no hygiene deficits were observed. The Veteran's attitude was calm and cooperative. He demonstrated no unusual movements or psychomotor changes and his speech proceeded at a normal rate, tone, and volume without pressure. His affect and mood were mildly depressed. His thought processes were goal-directed and logical. There was no evidence of hallucinations, delusions, obsessions, compulsions, or phobias. Testing indicated mild cognitive impairment. The examiner opined that the Veteran's PTSD symptoms appeared to be moderately impacting his functioning. He noted that the Veteran was able to maintain activities of daily living; however, his social functioning and employment were impaired by his symptoms. The examiner noted that it was difficult to assess how the Veteran's symptoms impacted his work performance because he was not currently employed. He reportedly "popped" a coworker that came up from behind and touched him. He denied missing any days of work or being late for work due to his symptoms. The examiner opined that the Veteran's symptoms impacted his relationships because he was unable to sleep in the same bed with his partners and he "felt controlled" in his relationships. A GAF score of 56 was assigned. In July 2012 and October 2012, the Veteran submitted photographs of weapons near a couch, a door, and a bed. On the back of one photograph, the Veteran indicated that the only way that he felt "safe" was when he slept with a loaded gun. During the October 2012 hearing, the Veteran testified that he was unable to secure employment because he was unable to "adapt." He reported that he had difficulty learning new skills. He stated that he had approximately ten relationships lasting no more than two years after his divorce in 1992; however, he was unable to sleep with anyone else in his room because of his inability to sleep. He indicated that he did not have any friends. He stated that he went fishing with his brother and his girlfriend occasionally, but he did not socialize. He testified that he did not feel comfortable around people and he just tried to "leave people alone." He reported that he drew and painted occasionally "to relax." The Veteran related that he took "nightmare medication" occasionally, but he did not like to sleep where he could not "react to anything." He stated that he fought sleeping all night and took naps during the day. He stated that he was only able to sleep when he had a loaded gun with him. He stated that he kept one gun by the side of his bed and another gun near his couch. He testified that he was hypervigilant when it came to noise around his home. He indicated that he thought about committing suicide several times, but he did not want to "take a chance on going to Hell if that's what lies ahead." He reported that he tried to avoid confrontation, but he thought that he had to kill a man approximately one and a-half years previously when the man entered his home drunk and belligerent. In light of the evidence summarized above, the Board finds that a 70 percent evaluation for PTSD is warranted. In this regard, the evidence shows that the Veteran has occupational and social impairment with deficiencies in the areas of work, family relations, thinking and mood. His PTSD is shown to be manifested by anxiety, intrusive thoughts, avoidance of crowds, impaired concentration, withdrawal, hypervigilance, exaggerated startle response, depressed mood and chronic sleep impairment. He has very few social relationships, a fear of crowds and little leisure activities. He reportedly spent most of his time alone or with his girlfriend or brother on occasion. At times, he has had suicidal thoughts. These findings justify a 70 percent evaluation. The Board notes that a 70 percent evaluation is consistent with the observations of the examiners. The Board notes that the GAF scores differed throughout the period of appeal. The GAF scores of 60 recorded in the December 2007 VA-sponsored QTC examination report, 55 recorded in the June 2009 VA examination report, and 56 recorded in the May 2012 VA examination report are indicative of moderate symptoms. However, a GAF score of 42 was assigned by a VA psychiatrist in December 2008. A GAF score of 42 is indicative of serious symptoms or any serious impairment in social or occupational functioning. Here, the most probative evidence establishes that the Veteran does have some serious symptoms, including suicidal ideation; however, the evidence suggests that the Veteran's impairment is more indicative of moderate symptoms. Therefore, the GAF score of 42 is unsupported and accorded little probative value. Rather, the more probative clinical findings support a 70 percent evaluation. The Board finds that an evaluation higher than 70 percent disabling is not warranted. To the extent, the May 2012 VA examiner found that the Veteran was able to maintain activities of daily living; however, his social functioning and employment were impaired by his symptoms. Additionally, the June 2009 examiner opined that the Veteran's social functioning was impaired by his high level of anxiety due to PTSD; however, he was employable from a psychiatric standpoint. The examiner opined that the Veteran was "best employed in areas in which he has little or no contact with the public and loose supervision, due to his high level of anxiety and frequency of panic symptoms." In this regard, the Veteran has been competent and credible when reporting his symptoms. The Board acknowledges his reports of occupational difficulties, suicidal thoughts, social withdrawal, fear of crowds, nightmares, depressed mood and memory/concentration problems. The Board also acknowledges that examination has revealed his mood was anxious, affect dysthymic, and judgment and insight limited. The above, however, have been considered and contemplated in the 70 percent evaluation. Neither the lay or credible medical evidence shows these symptoms have been persistent or rises to the level required for a 100 percent evaluation. The evidence shows that the Veteran is without inappropriate behavior, obsessive/ritualistic behavior, panic attacks, homicidal thoughts and/or problems with daily living. It is also noted that his suicidal thoughts are without intent or plan. Furthermore, despite having deficiencies in family relations, the Board notes that the Veteran has a girlfriend and he has reported that he occasionally goes fishing with his brother. Such findings do not warrant a 100 percent evaluation when all the other manifestations are considered. See Mauerhan, 16 Vet. App. 436. Stated differently, the medical and lay evidence as well as the GAF scores establish that there is occupational and social impairment with deficiencies in most areas. The manifestations, however, even when accepted as credible, do not establish total impairment. In sum, the Veteran's symptoms are more characteristic of a disability picture that is contemplated by a 70 percent rating and no more. Regarding referral for extraschedular consideration, consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. Here, the Board finds that the Veteran has not required frequent periods of hospitalization for his disability and that the manifestations of the disability are contemplated by the schedular criteria. Therefore, there is no reason to believe that the average industrial impairment from the disability would be in excess of that contemplated by the schedular criteria. Therefore, referral of the case for extra-schedular consideration is not in order under 38 C.F.R. § 3.321. ORDER An evaluation of 70 percent disabling for PTSD is granted, subject to the controlling regulations applicable to the payment of monetary benefits. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs