Citation Nr: 1304263 Decision Date: 02/06/13 Archive Date: 02/19/13 DOCKET NO. 10-08 858 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD), to include whether the assignment of a total disability rating based upon individual unemployability (TDIU) is warranted for this disability. REPRESENTATION Veteran represented by: Oklahoma Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD V. Chiappetta, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from September 1966 to September 1969. This matter is before the Board of Veterans' Appeals (the Board) on appeal of a July 2009 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which denied the Veteran's claim for a disability rating greater than 50 percent for his service-connected PTSD. The Veteran disagreed with the RO's determination, and perfected an appeal as to that issue. In July 2011, the Veteran testified at a personal hearing, conducted via videoconferencing equipment, which was chaired by the undersigned Acting Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the Veteran's VA claims folder. In October 2011, the Board remanded the Veteran's PTSD claim for additional evidentiary development. Such was achieved, and the Appeals Management Center (AMC) readjudicated the Veteran's claim in a July 2012 supplemental statement of the case (SSOC). The Veteran's claims file has been returned to the Board for further appellate review. The Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (the Court) held that a claim for a TDIU due to service-connected disability is part and parcel of an increased rating claim for that disability when raised by the record. During the adjudication of the Veteran's increased rating claim for PTSD, the issue of entitlement to TDIU has in fact been raised by medical evidence of record, specifically by Dr. R.A.C. in his December 2011 VA examination report. See the December 2011 VA examiner's report, page 7 [indicating that the Veteran's PTSD symptoms "lead to a decreased ability for the veteran to maintain gainful employment."]. In light of the Court's holding in Rice, the Board has considered the TDIU claim as part of his pending increased rating claim, and has incorporated it with the issue on appeal. The Board has reviewed the Veteran's physical claims file and the record maintained in the Virtual VA paperless claims processing system. FINDINGS OF FACT 1. The evidence of record demonstrates that throughout the period under review, the Veteran's service-connected PTSD has manifested in disability tantamount to occupational and social impairment with reduced reliability and productivity, warranting the assignment of a 50 percent disability rating. 2. The lay and medical evidence of record fails to demonstrate such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected PTSD is inadequate. 3. The Veteran is currently service-connected for PTSD, rated 50 percent disabling, and for tinnitus, rated 10 percent disabling. These evaluations do not meet the schedular requirements for assignment of a total disability rating based on individual unemployability. 4. The evidence of record does not demonstrate that the Veteran's service-connected PTSD renders him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for the assignment of a disability rating greater than 50 percent for service-connected PTSD are not met, and there is no evidence to warrant referral for consideration of a higher rating on an extraschedular basis. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(b), 4.130, Diagnostic Code 9411 (2012). 2. The criteria for assignment of a TDIU are not met, and there is no evidence to warrant referral for consideration of individual unemployability on an extraschedular basis. 38 C.F.R. §§ 3.340 , 4.16(a) and (b) (2012); Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Stegall concerns As noted in the Introduction above, the Board remanded the Veteran's PTSD claim in October 2011 for additional evidentiary development. In particular, the Board instructed the agency of original jurisdiction (AOJ) to schedule the Veteran for an updated VA psychiatric examination to determine the current severity of his service-connected PTSD. The Veteran appeared for this examination in December 2011. The VA examiner's findings were responsive to the Board's October 2011 inquiries, and the corresponding examination report has been associated with the Veteran's claims file. As noted above, the AMC readjudicated the Veteran's claim in a July 2012 SSOC. Thus, there is compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), 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. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate 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 notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim, defined to include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board also notes that the Court has held that the plain language of 38 U.S.C.A. § 5103(a) 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 RO provided the Veteran with adequate notice under the VCAA and Dingess specific to his increased rating claim in a June 2009 letter. This letter notified the Veteran that to support a claim for an increased rating for PTSD, the evidence must show a "worsening or increase in severity and the effect that worsening or increase has on your employment and daily life." See the June 2009 VCAA letter, page 5. Subsequently, in July 2009, the RO adjudicated the Veteran's increased rating claim in the first instance, and the Veteran filed a timely appeal as to the RO's determination. Accordingly, with respect to VCAA notice, there is no prejudice to the Veteran in the Board's proceeding with the issuance of a decision on the merits as to his PTSD increased rating claim, to include that part of the claim specific to whether PTSD is so severe as to render him unable to secure or follow a substantially gainful occupation. As noted above, a claim for TDIU due to a specific disability is part and parcel of a claimant's increased rating claim for that disability when reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Concerning the VA's duty to assist, the Board notes that the Veteran's service treatment records, service personnel records, post-service VA treatment records, and his lay statements of argument have been obtained. The Veteran has not identified any outstanding evidence, to include any other medical records, that could be obtained to substantiate his appeal. The Board notes that the Veteran clarified at his July 2011 hearing that although he does receive benefits from the Social Security Administration (SSA), such are awarded for his retirement in 2011 and not for disability. See July 2011 hearing transcript, page 6. Although it appears the Veteran may have attempted to secure SSA disability benefits years ago in 1995 [see the Veteran's November 8, 1995 release form identifying a representative in an appeal for SSA and Medicare/Medicaid benefits], neither the Veteran nor his representative has asserted that there are any existing records associated with this eighteen-year old SSA appeal that would be relevant to his current claim for an increased disability rating for PTSD, filed in June 2009. The Board identifies nothing in the record that would establish a reasonable possibility that any SSA records associated with a 1995 appeal, if in existence, would aid in identifying the level of severity of the Veteran's PTSD during the current period under review. As such, remand to request such records is not necessary in this case. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) [holding that VA is not required to obtain SSA records in all cases but only where potentially relevant to the claims on appeal]. With respect to the examinations conducted in conjunction with this appeal, the Board observes that the findings contained therein are more than adequate to adjudicate the Veteran's claim. The Veteran appeared for a QTC fee-based examination in July 2009, and a VA psychiatric examination in December 2011. These examination reports reflect that each VA examiner reviewed or was made aware of the Veteran's past medical history, recorded the Veteran's complaints, conducted an appropriate interview and examination, and rendered appropriate diagnoses consistent with the other evidence of record. The December 2011 VA examiner was responsive to the Board's inquiries, outlined in its October 2011 remand instructions, and included discussion of the impact the Veteran's PTSD has, if any, on his ability to secure or follow a substantially gainful occupation. The Board notes that although the Veteran's PTSD was last evaluated over one year ago, the Board does not believe that the medical evidence of record in this case is too old to adequately evaluate the severity of the Veteran's service-connected disability. The Veteran has not stipulated that his PTSD symptoms have worsened in severity since his December 2011 examination, and the Veteran has submitted no evidence suggesting that there has been a change in the severity of such disability. Thus, the Board does not believe that the medical evidence of record in this case is too old to adequately evaluate the Veteran. See VAOPGCPREC 11-95 [a claim need not be remanded solely because of the passage of time when an otherwise adequate VA examination was conducted]; see also Palczewski v. Nicholson, 21 Vet. App. 174 (2007) [another VA examination is not warranted based on the mere passage of time]. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions concerning the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007). Finally, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the Board hearing, the undersigned complied with the holding of Bryant by explaining the issue on appeal adjudicated on the merits in the instant decision. The Veteran, with his representative and with questions from the undersigned, discussed evidence of record. The transcript of the Board hearing details that the evidence regarding the Veteran's PTSD symptomatology was discussed at length. As the issue on appeal was fully explained and the questions at the hearing went directly to the evidence needed to grant the benefit sought (that is, increased or worsened symptomatology) the Board finds that there was substantial compliance with Bryant. In short, the Board has carefully considered the provisions of the VCAA, in light of the record on appeal and, for the reasons expressed above, finds that the development of the Veteran's claim has been consistent with said provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the issue on appeal were insignificant and nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of his claim. See 38 C.F.R. § 3.103 (2012). Accordingly, the Board will address the issue on appeal. Legal Criteria Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. The Veteran's psychiatric disorder is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 [PTSD] (2012). Under the current criteria, Diagnostic Code 9411 is deemed by the Board to be the most appropriate primarily because it pertains specifically to the diagnosed disability in the Veteran's case. In any event, with the exception of eating disorders, all mental disorders including PTSD are rated under the same criteria in the Rating Schedule. Therefore, rating under another diagnostic code would not produce a different result. The Board can identify nothing in the evidence to suggest that another diagnostic code would be more appropriate, and the Veteran has not requested that another diagnostic code be used. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9411. The pertinent provisions of 38 C.F.R. § 4.130 relating to rating mental disorders read as follows: 100 Percent: 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. 70 Percent: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 50 Percent: 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Codes 9411 and 9440 (2012). 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. 38 C.F.R. § 4.126(a) (2012). 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(b). Global Assessment of Functioning (GAF) scores are 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 the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV), page 32]. According to the DSM-IV, GAF scores ranging between 51 to 60 reflect 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 Board notes that an examiner's classification of the level of psychiatric impairment by a GAF score is to be considered, but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. With respect to TDIU, under the applicable criteria, all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16 (2012). A finding of total disability is appropriate when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. See 38 C.F.R. §§ 3.340(a)(1), 4.15. In determining whether unemployability exists, consideration may be given to a veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. A total disability rating for compensation purposes may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and the combined rating must be 70 percent or more. See 38 C.F.R. § 4.16(a). Pursuant to 38 C.F.R. § 4.16(b), when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), such case shall be submitted to the Director of the Compensation and Pension Service for extraschedular consideration. Analysis A. Schedular rating - PTSD In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. In reaching its conclusion, the Court observed that when a claim for an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received if it is factually ascertainable that an increase in disability had occurred within that timeframe. See 38 U.S.C.A. § 5110 (West 2002). Accordingly, the relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. The Veteran filed his claim for an increased disability rating for his service-connected PTSD in June 2009. Therefore, the question to be answered by the Board is whether it is factually ascertainable that any different rating should be assigned for the relevant time period under consideration, or June 2008 to the present. Indeed, the Veteran's PTSD has been rated 50 percent disabling for all times dating from June 2008 to the present day. The Board initially notes that at no time during the period under review has the Veteran sought medical treatment for his psychiatric disability. Other than examination reports dated in July 2009 and December 2011, there are no other recent clinical findings that can be reviewed to assess the severity of the Veteran's PTSD disability. As noted above, the Veteran did supplement the record with his own lay testimony and argument at a July 2011 hearing before the undersigned. In addition, the Board notes that well before the appeal period, an April 2005 QTC examiner diagnosed the Veteran with an alcohol abuse disability that was due to his PTSD. The examiner did not distinguish the Veteran's mental health symptomatology between the two disabilities. See the April 2005 QTC examiner's report, page 2. Subsequently, the July 2009 QTC examiner similarly noted that, in addition to PTSD, the Veteran suffered from a panic disorder and alcohol abuse. This examiner did distinguish symptomatology among disabilities, but pertinently stated that the Veteran's PTSD caused both the panic disorder and alcohol abuse. See the July 2009 QTC examiner's report, page 3. In contrast, and most recently, the December 2011 VA examiner specifically determined after review of the record and upon examination of the Veteran that the Veteran did not have a panic disorder, and that although a history of alcohol abuse exists, the evidence does not support a current diagnosis, "nor is it a factor in the veteran's condition." See the December 2011 VA examiner's report, page 7. The Board is precluded from differentiating between symptomatology attributed to a service-connected disability and a nonservice-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In the instant case, although it appears that the Veteran may not have a panic disorder or alcohol abuse problem presently [as per the findings of the December 2011 VA examiner], when prior examiners did mention the presence of such disabilities, they specified that such were caused by, or represented progressions of the Veteran's service-connected PTSD. As such, in considering the propriety of the 50 percent disability rating in place during the entirety of the period under review, the Board will resolve all doubt in the Veteran's favor and accordingly consider all of the Veteran's psychiatric symptomatology, whether attributed to a panic or alcohol abuse disability or not, to be related to his service-connected PTSD. As noted above, for the assignment of a 70 percent disability rating, the Veteran's PTSD must have manifested in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Crucially, the focus of this inquiry is not necessarily limited to analysis of the symptomatology listed in the VA rating schedule [see Mauerhan v. Principi, 16 Vet. App. 436 (2002)], but includes analysis of how the Veteran's PTSD symptomatology affects his "occupational and social impairment," if at all. After reviewing evidence of record as a whole, to include the Veteran's mental health examination reports and his competent lay statements, the Board finds that the assignment of a disability rating greater than 50 percent for the Veteran's service-connected PTSD is not warranted at any time during the period under review. Focusing first on the one year period prior to the Veteran's January 2009 claim for increase, as noted above, the Veteran did not receive any treatment for his service-connected PTSD between January 2008 and January 2009. Significantly, the conclusions of the April 2005 QTC examiner are the only objective medical indicators of record as to the severity of the Veteran's PTSD as it existed years prior to his increased rating claim. Notably, the RO specifically relied on the findings of the April 2005 QTC examiner when it awarded the Veteran an increased disability rating from 30 to 50 percent for his PTSD in an unappealed May 2005 rating decision. To the extent the Veteran is now highlighting findings of the April 2005 examiner in support of his current claim for an increased rating [see the Veteran's August 2009 notice of disagreement, referencing a GAF score of 35 assigned by the April 2005 QTC examiner], the Board finds that such findings are too far removed from the date of the Veteran's claim to be probative in this case. In any event, the Veteran has not alleged that his PTSD symptoms worsened in severity from the time he appeared for his April 2005 QTC examination, and the time he filed his claim for an increased disability rating in June 2009. Shortly after the Veteran filed his June 2009 increased rating claim, the Veteran appeared for another QTC examination in July 2009. The July 2009 examiner reiterated that the Veteran had not received any medical treatment for his PTSD, to include hospitalization, psychotherapy or emergency room visits. The Veteran reported frequent anger outbursts, irritability and isolation from others, and noted that socially, he prefers to stay at home. At the time, he was employed, and he described his relationship with his supervisor and co-workers as "fair." He had not lost any time from work. Upon examination, the examiner pertinently observed "normal" orientation, affect and mood, speech, and communication, and "appropriate" appearance and hygiene, behavior, and thought processes. Although the Veteran did report panic attacks occurring more than once per week marked by feeling he is dying, heart racing and dizziness, the Veteran reported no suspiciousness, or history of delusions, hallucinations or obsessional rituals. The Veteran also did not exhibit impaired judgment, suicidal or homicidal ideation, or slowness of thought. Notably, the examiner did report that the Veteran has isolated himself from others, including his wife. After reviewing the Veteran's history and upon examination of the Veteran, the July 2009 examiner diagnosed the Veteran with PTSD and assigned a GAF score of 51, which as noted above, is indicative of 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 examiner concluded that the Veteran "occasionally has some interference in performing activities of daily living because [he] often has difficulty finding the motivation to work due to his aggression with people." The examiner also noted that the Veteran has "difficulty establishing and maintaining effective work/school and social relationships because [he] spends the time he is not working alone." He has "occasional" interference with recreation or leisurely pursuits, and outpatient counseling was recommended. See the July 2009 QTC examiner's report, pages 3 and 4. At the July 2011 hearing, the Veteran testified that he believed his PTSD symptoms worsened in severity since his July 2009 QTC examination. He had retired from his job because he believed he could no longer work with his boss due to his disability, and he was getting too worried. He determined it would be best to leave, so he retired. See the July 2011 hearing transcript, pages 3 and 4. Socially, the Veteran indicated that he lives by himself and does not see his family very much. See id., page 4. Based on the Veteran's testimony, VA scheduled the Veteran for another examination in December 2011. At that examination, the Veteran reported that from a social standpoint, he only goes off his property once or twice a month to do banking and grocery shopping, and sees his children once per month, with some interaction with his grandchildren. The Veteran indicated that he was divorced but "recently started seeing a woman and states that this has helped him to stay 'calmed down'." See the December 2011 VA examiner's report, page 4. Occupationally, the Veteran again noted that he liked his job, which he had performed for the past twelve and a half years, but started having recent conflict with his boss. The examiner noted that "when [the Veteran] reached the age where he could claim social security retirement he decided to retire." The Veteran again reported that he received no treatment for his mental problems. See id., page 4. Upon examination, the VA examiner noted the presence of symptoms such as anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and an inability to establish and maintain effective relationships. The Veteran was oriented, with clear thought processes, and normal memory and concentration. He pertinently denied feelings of depression, suicidal ideation or intent, or any intent to harm others, although recognizing that he gets angry in certain situations and isolates himself to cope with these feelings. The examiner diagnosed the Veteran with PTSD, and noted that he has "difficulty with social relationships and maintains an isolation from others," assigning a GAF score of 60, which again, is indicative of more moderate symptoms or moderate difficulty in social and occupational functioning as stipulated by the DSM-IV. Crucially, when specifically asked to summarize the Veteran's level of occupational and social impairment, the December 2011 VA examiner ultimately determined that the Veteran's PTSD was manifested by "occupational and social impairment with reduced reliability and productivity," mirroring the language included in the ratings criteria used to described the level of impairment warranting the assignment of a 50 percent disability rating. See the December 2011 VA examiner's report, page 3; see also 38 C.F.R. § 4.130, Diagnostic Codes 9411 and 9440 (2012). The Veteran has not submitted any other additional lay or medical evidence suggesting his disability picture has worsened in severity since his December 2011 VA examination. After review of all of the above lay and medical evidence, it is clear to the Board that the Veteran has PTSD of moderate severity manifested by "occupational and social impairment with reduced reliability and productivity," warranting the assignment of a 50 percent rating under Diagnostic Code 9411. The Veteran has competently and credibly articulated experiencing disturbances of motivation and mood, as well as difficulty in establishing and maintaining effective work and social relationships, and the medical evidence of record supports these observations. The evidence however does not demonstrate that the Veteran's PTSD causes occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking or mood, warranting the assignment of a higher 70 percent disability rating, or total occupational and social impairment, warranting the assignment of a 100 percent rating. Indeed, although the December 2011 VA examiner did note that the Veteran experiences difficulty in adapting to stressful circumstances, including work or a worklike setting, and an inability to establish and maintain effective relationships [symptoms generally attributed to those experiencing more severe PTSD, warranting a 70 percent rating], the evidence demonstrates that even though the Veteran had a conflict with his boss prior to retirement in 2011, he did retire on his own accord because it occurred at a time he was in fact eligible for Social Security retirement benefits. Additionally, while it is clear the Veteran does spend most of his time in isolation, the evidence does not support a finding that the Veteran is unable to establish and maintain an effective relationship, as the Veteran has specifically noted that he is indeed seeing a woman that helps keep him calm. See the December 2011 VA examiner's report, page 4. As noted above, the VA examiner assigned a GAF score of 60, and specifically opted not to characterize the Veteran's overall disability picture as one manifesting in occupational and social impairment with deficiencies in most areas [as per the criteria for a 70 percent rating] or total occupational and social impairment [as per the criteria for a 100 percent rating]. Rather, based on the Veteran's reported history and clinical picture, the examiner summarized the Veteran's overall disability as one manifesting in occupational and social impairment with reduced reliability and productivity, as per the criteria for a 50 percent rating. Although the Veteran has described problems with stress, anger and isolation, the Veteran has not exhibited other symptoms identified by the ratings criteria as potentially present in individuals with social and occupational impairment severe enough to warrant a 70 percent disability rating, to include suicidal ideation, homicidal ideation, obsessional rituals that interfere with routing activities, illogical speech, near-continuous panic or depression affecting the ability to function independently or appropriately, impaired impulse control, spatial disorientation or neglect of personal appearance and hygiene. In the same vein, the Veteran has exhibited no symptoms listed in the ratings criteria that are identified by the ratings criteria as potentially found in those with total occupational and social impairment warranting a 100 percent disability rating. The Board is aware of the Court's holding in Mauerhan, referenced above. In evaluating to what extent the Veteran's PTSD symptomatology impairs his occupational and social abilities, to include the impact of those symptoms listed in the ratings criteria, as well as those not listed in the criteria that are described by the Veteran and the medical examiners of record [such as the Veteran's isolation], the Board has identified no other aspects of the Veteran's service-connected PTSD which would enable it to conclude that the criteria for a rating greater than 50 percent have been approximated at any time during the period under review, and the Veteran and his representative have pointed to no such symptomatology. As noted above, the Veteran has not received any medical treatment for his PTSD at any time. In not granting a 70 percent or 100 percent schedular rating for PTSD, the Board is not minimizing the severity of the Veteran's symptoms. These symptoms, while productive of moderate impairment, are not so severe that they cause occupational and social impairment with deficiencies in most areas, or total occupational or social impairment. Despite demonstrated difficulties with mood, anger and isolation, the Veteran is clearly able to function socially, and has demonstrated this ability by initiating a relationship with a woman who he states has helped him become a calmer person. As noted above, the Veteran retired from his job of twelve and a half years on his own accord based on what the December 2011 VA examiner described as the Veteran's "perceived" need for social isolation and increased anger and irritability. Notably, the Veteran admitted to the VA examiner that he was eligible for Social Security retirement benefits at the time of his retirement, and that his intent was only to retire for a year. See the December 2011 VA examiner's report, pages 4 and 7. Hence, while the Veteran may have some difficulty with employment and maintaining relationships with others due to his PTSD symptoms, the evidence does not demonstrate the presence of severe or total social impairment. Indeed, the level of impairment that is demonstrated is already contemplated in the assignment of a 50 percent rating. Based on all of the above, the Board finds that an increased disability rating greater than 50 percent is not warranted at any time during the period under review. The Veteran's application for a higher schedular rating for his service-connected PTSD is denied. B. Extraschedular rating - PTSD Under Floyd v. Brown, 9 Vet. App. 88, 95 (1996), the Board cannot make a determination as to an extraschedular evaluation in the first instance. See also VAOPGCPREC 6-96. However, the Board can address the matter of referral of a disability to appropriate VA officials for such consideration. Under the applicable criteria, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); see also Fanning v. Brown, 4 et. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, 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 claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's 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 Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's service-connected PTSD are inadequate. A comparison between the levels of severity and symptomatology of the Veteran's PTSD with the established criteria found in the rating schedule shows that the rating criteria reasonably describes the Veteran's disability levels and symptomatology. In particular, as discussed in detail above, the Veteran's PTSD manifests in occupational and social impairment with reduced reliability and productivity - impairment specifically contemplated under the mental illness ratings criteria for the currently-assigned 50 percent rating. The record does not reflect that the Veteran's PTSD causes occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking or mood, or total occupational and social impairment. Accordingly, the Board finds that the Veteran's disability picture has been contemplated by the ratings schedule. Since the available schedular evaluations adequately contemplate the Veteran's levels of disability and symptomatology for his service-connected PTSD, the second and third questions posed by Thun become moot. In short, there is nothing in the record to indicate that the Veteran's service-connected PTSD causes impairment over and above that which is contemplated in 50 percent disability rating that is currently assigned. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. C. Entitlement to a total disability rating based on individual unemployability (TDIU) as due to PTSD The Board has already explained in its Introduction that entitlement to TDIU, when raised by the record, is an element of all claims for a higher initial rating, and not a separate claim for benefits. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In this case, the issue of entitlement to TDIU has been raised by medical evidence of record, specifically by Dr. R.A.C. in his December 2011 VA examination report. See the December 2011 VA examiner's report, page 7 [indicating that the Veteran's PTSD symptoms "lead to a decreased ability for the veteran to maintain gainful employment."]. As such, the question of whether a TDIU is warranted is in fact part of the Veteran's increased rating claim, and will be discussed as an alternate theory of entitlement to an rating greater than 50 percent for service-connected PTSD. As has been discussed in the law and regulations section above, TDIU may be awarded on either a schedular basis or an extraschedular basis. With respect to a schedular TDIU award, a total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. See 38 C.F.R. § 4.16(a) (2012). In this case, the Veteran's PTSD has been rated 50 percent disabling for the entire period under review. He is also service-connected for tinnitus, rated 10 percent disabling since February 2005, with a combined rating of 60 percent also in effect since February 2005. Based on these ratings, both for PTSD individually, and for both service-connected disabilities in combination, it is clear that the Veteran does not meet the criteria for consideration of TDIU on a schedular basis at any time during the period under review. See 38 C.F.R. § 4.16(a) (2012). Pursuant to 38 C.F.R. § 4.16(b), when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), such case shall be submitted to the Director of the Compensation and Pension Service for extraschedular consideration. For the reasons explained below, the Board finds that referral of the Veteran's case to the Director of the Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 4.16(b) is not required, as the evidence of record fails to demonstrate that the Veteran's service-connected PTSD rendered him unable to secure or follow gainful employment within the time period under review. The Board wishes to make clear that neither the Veteran nor his representative have asserted or even suggested that the Veteran's service-connected tinnitus has caused or contributed to the Veteran's unemployability. As the Veteran's TDIU claim is part and parcel of his claim for an increased PTSD rating, the inquiry will focus primarily on the effects of the Veteran's PTSD on his employability. The Veteran's employment history reflects that he last held a job for over twelve years as a developmental disability job coach. While a coach, he supervised a crew in doing cardboard recycling, and indicated that his mission was to "make these participants 'community ready.'" He generally liked the job and felt he was helping others. See the December 2011 VA examiner's report, page 4. At his July 2011 hearing, the Veteran stated that he stopped working in 2011. When asked the reason for leaving, the Veteran responded that he "just retired." He did however indicate that he did not have a good relationship with his boss at the time of his retirement, and felt he could no longer work with him due to his disability. See the July 2011 hearing transcript, pages 3 and 4. The Veteran similarly told the December 2011 VA examiner that he started to have conflicts with his boss, but retired when he reached the age where he could claim Social Security retirement benefits. The Veteran expressed an intent to retire for one year only, and that the year was almost up. See the December 2011 VA examiner's report, page 4. After assessing the severity of the Veteran's PTSD, the December 2011 VA examiner pertinently reported that the Veteran's symptoms "lead to a decreased ability for the veteran to maintain gainful employment." The examiner noted that the Veteran's "perceived need for social isolation and increased anger and irritability led him to take a retirement." Finally, the examiner concluded that the results do not support the contention that the veteran is unemployable, but do significantly reduce the likelihood of successful employment. See the December 2011 VA examiner's report, page 7. While it is clear from the December 2011 VA examiner's findings that the Veteran's PTSD hinders the Veteran's ability to sustain or follow gainful employment, the record does not demonstrate that the Veteran's PTSD prevents the Veteran from sustaining or following gainful employment. Indeed, the medical evidence of record, discussed in detail above, demonstrates that the Veteran's PTSD only manifested in moderate symptomatology with little to no impact on the Veteran's judgment, insight, orientation, focus, concentration, thinking, mood, or speech. Additionally, the Veteran's GAF scores during the appeal period ranged from 51 to 60, which the DSM-IV identifies as indicative of only moderate occupational impairment from PTSD symptomatology. Although the Board in no way doubts that the Veteran's conflict with his boss at the end of his employment in February 2011 was a contributing factor in his decision to retire, it is clear that the Veteran also decided to retire in large part due to his eligibility for Social Security retirement benefits. He intended to take a year off of work and potentially return to the workforce. The December 2011 VA examiner made clear that it was the Veteran's "perceived" need for isolation and irritability that led him to take a retirement, adding that the results of the Veteran's examination do not support the contention that the Veteran is unemployable. The Board does not in any way disagree that the Veteran's service-connected PTSD limited his employability to some extent during the period under review. The Board believes, however, that the symptomatology associated with the service-connected PTSD is appropriately compensated by the 50 percent initial rating which is currently assigned. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1. Indeed, 38 C.F.R. § 4.1 states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. Thus, while in no way diminishing the obvious impact the Veteran's PTSD has on his industrial capacity, this is already taken into consideration in the assigned rating. In conclusion, for the reasons and bases expressed above the Board finds that a TDIU award is not warranted on a schedular basis under the provisions of 38 C.F.R. § 4.16(a), and that referral to appropriate authority for consideration on an extraschedular basis under the provisions of 38 C.F.R. § 4.16(b) for the period under review is also not required in this case. ORDER Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD), to include whether the assignment of a total disability rating based upon individual unemployability (TDIU) is warranted for this disability, is denied. ____________________________________________ Nathaniel J. Doan Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs