Citation Nr: 1304832 Decision Date: 02/11/13 Archive Date: 02/21/13 DOCKET NO. 10-11 235 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an initial disability evaluation in excess of 50 percent for posttraumatic stress disorder ("PTSD"). REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. Y. Hawkins, Counsel INTRODUCTION The Veteran served on active duty from October 1966 to October 1968. This matter comes before the Board of Veterans' Appeals ("Board") on appeal from an October 2007 rating decision issued by the Department of Veterans Affairs ("VA") Regional Office ("RO") in Montgomery, Alabama, which granted the Veteran's claim of entitlement to service connection for PTSD with an initial rating of 30 percent, effective September 8, 2006. Following a timely notice of disagreement, in a February 2010 rating decision, the RO increased the Veteran's disability evaluation for PTSD to 50 percent, effective September 8, 2006. Despite the assignment of an increased disability evaluation for this disorder, the issue remains in appellate status because the Veteran has continued to express disagreement with the assigned rating. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (a rating decision issued after a notice of disagreement which grants less than the maximum rating available does not "abrogate the pending appeal"). In July 2012, the Veteran testified at a Board video conference hearing before the undersigned Veterans Law Judge sitting in Washington, DC. A transcript of the hearing has been associated with the Veteran's claims folder. During the hearing, the Veteran requested that the record be held open for 30 days to allow him to submit additional evidence, accompanied by a waiver of regional review. See 38 C.F.R. § 20.709 (2012). However, despite the fact that the record remained open, the Board did not receive any additional evidence. FINDINGS OF FACT Throughout the course of this appeal, the Veteran's PTSD has been manifested by symptoms no greater than no greater than occupational and social impairment with reduced reliability and productivity (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to chronic sleep impairment; nightmares; anger and irritability; panic attacks more than once per week; depression; mild memory and concentration loss; emotional avoidance and numbing; suspiciousness; hyperarousal; exaggerated startle response; infrequent flashbacks; and difficulty adapting to stressful circumstances (including work or a worklike setting). CONCLUSION OF LAW The criteria for an initial evaluation in excess of 50 percent disabling for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.27, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 ("VCAA") With respect to the Veteran's claim decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). A.) Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) ("Pelegrini II"), the United States Court of Appeals for Veterans Claims ("Court") held that 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; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his or her possession that pertains to the claim. Element (4), however, the requirement of requesting that the claimant provide any evidence in his possession that pertains to the claim, was eliminated by the VA Secretary ("Secretary") during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini, effective May 30, 2008). The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Of particular importance, in Dingess/Hartman, the Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection is awarded. In this case, service connection for PTSD has already been established, and the current appeal arose from a claim for an increased initial disability rating. In such cases, the Court has held that where service connection has been granted and the initial rating has been assigned, the service connection claim has been more than substantiated - it has been proven. See Dingess/Hartman, supra. As such, 38 U.S.C.A. § 5103(a) notice is no longer required, since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, any defect as to notice with regard to the current claim is nonprejudicial. See Dingess, 19 Vet. App. at 490-91; Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). Here, by means of a letter dated October 2007, the Veteran was informed of the evidence needed to substantiate his original service connection claim and also satisfied the requirements of Dingess/Hartman by informing him how VA assigns the disability rating and effective date elements of a claim. Moreover, in February 2010, following the receipt of his notice of disagreement with the initial rating, he was afforded a Statement of the Case ("SOC"), which provided him with the rating criteria used by VA in evaluating mental health disabilities, including the criteria for establishing a disability evaluation in excess of 30 and 50 percent. B.) Duty to Assist The Board concludes that VA's duty to assist has been satisfied. The claims folder contains the Veteran's service and post-service treatment records, as well as VA PTSD examinations dated September 2007, December 2009 and February 2012, respectively. The claims folder also contains the Veteran's statements and hearing testimony in support of his claim. The Veteran has not referenced any outstanding records that he wanted VA to obtain or that he felt were relevant to his claim that have not already been obtained and added to the record. Review of the VA examination reports show that the examiners reviewed the complete claims folder, elicited from the Veteran a history of his self-reported symptomatology, reviewed diagnostic test results and provided the results of their comprehensive examinations. Accordingly, the Board finds that the VA PTSD examinations reports are adequate upon which to base a decision in this case. 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 claim has been consistent with the provisions of the VCAA. The appellant has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to the VCAA notice. The purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his appealed claim. II. Law and Regulations The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Under 38 U.S.C.A. § 1154(a), VA is also required to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. In Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit ("Federal Circuit") held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3), lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." (footnote omitted). However, the Court has held that "[t]he type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed." Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, and by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries, and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate Diagnostic Codes ("DCs") identify the various disabilities and the criteria for specific ratings. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2009). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (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. 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. The Veteran's service-connected PTSD has been evaluated under DC 9411. The regulations establish a general rating formula for mental disabilities. See 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) ("DSM-IV"). The criteria for the current 50 percent rating are: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: 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. And, the criteria for a 100 percent rating are: 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. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). The Board must consider the Global Assessment of Functioning ("GAF") scores that have been reported. 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 DSM-IV, p.32). GAF scores from 61 to 70 represent some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful personal relationships. GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school function (such as few friends, conflicts with peers or co-workers). GAF scores ranging from 41 to 50 reflect 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). Additionally, scores ranging from 31 to 40 reflect 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 other children, is defiant at home, and is failing at school). Lower GAF score represent a greater degree of psychological, social, and occupational functioning. See 38 C.F.R. § 4.130 (incorporating by reference VA's adoption of the DSM-IV, for rating purposes). While an examiner's classification of the level of psychiatric impairment reflected in the GAF score assigned is probative evidence of the degree of disability, such a score is by no means determinative of the rating assigned by VA in evaluating a psychiatric disorder under the rating criteria. See 38 C.F.R. §§ 4.2, 4.126; VAOPGCPREC 10-95 (March 31, 1995). Rather, VA must take into account all of the veteran's symptoms and resulting functional impairment as shown by the evidence of record in assigning the appropriate rating, and will not rely solely on the examiner's assessment of the level of disability at the moment of examination. See 38 C.F.R. § 4.126. III. Factual analysis The Veteran contends that the symptoms of his PTSD are of greater severity than the current 50 percent rating contemplates. Review of the claims folder reveals that the Veteran submitted an informal claim for VA benefits in September 2006, followed by a formal claim in January 2007. In September 2007, he was afforded a VA PTSD examination, at which time, he told the VA examiner that he had been participating in VA PTSD group therapy since 2006, which he said had been helpful and effective. It was noted that the Veteran had served in combat during the Vietnam war and had been awarded the Purple Heart. In discussing his personal relationships, he said that he and his wife "tolerate[d] each other," and that he had a good rapport with his adult children. Although he said he had no current social relationships outside of his immediate family, he noted that he enjoyed such leisurely activities as hunting and fishing. Significantly, although he denied having a history of violence, he admitted that he had recently killed his wife's dog by beating it with his fists. During the mental status evaluation, he was neatly groomed and dressed, oriented in all spheres, cooperative and friendly with clear speech, normal affect, depressed mood and an unremarkable thought process. His insight and judgment was deemed to be within normal limits. He endorsed chronic sleep impairment, anger and irritability, exaggerated startle response and hypervigilance, but denied hallucinations, panic attacks, and homicidal or suicidal ideations. His remote and immediate memory were deemed normal, while his recent memory was moderately impaired. The Veteran was diagnosed with PTSD, chronic, moderate; his assigned GAF score was 55, reflecting moderate symptoms. VA Medical Center ("VAMC") outpatient treatment records show that the Veteran continued his participation in PTSD group therapy and received supportive therapy during individual outpatient treatment with VA mental health practitioners. During a July 2009 appointment with a physician, it was noted that the Veteran was taking several psychotropic medications, including Trazodone and Celexa for depression. His PTSD symptomatology included weekly flashbacks and nightmares, exaggerated startle response, hypervigilance and irritability. He denied suicidal or homicidal ideations. During the mental status evaluation, he was neatly groomed and cooperative, depressed, spoke with a normal rate of speech, had a constricted affect, and a linear thought process. He was alert and oriented times three, and denied hallucinations. The clinician diagnosed the Veteran with PTSD and depressive disorder, not otherwise specified ("NOS"). It was also noted that recent pain from a kidney stone was adding to his stress level. In December 2009, the Veteran was afforded a second VA PTSD examination pursuant to his NOD with the initial 30 percent disability rating. At that time, he reported that he was experiencing panic attacks 3-4 times per week, as well as audiovisual hallucinations. He reported that he was continuing in VA group therapy and was now taking three psychotropic medications without side effects. He now reported that the group therapy was only "fairly" effective, but admitted that it helped him deal better with his problems and get along better with his wife. Again, he described his marriage as one of tolerating one another, but now said he barely had any relationship at all with his adult children and grandchildren. Regarding other relationships, he admitted to having two close friends (one from his VA therapy group and another buddy from Vietnam), with whom he occasionally met to go fishing. His individual daily activities included fishing, computer games and walking 1.5 miles. During the mental status evaluation, he was clean and well-groomed, restless, tense, cooperative, attentive, agitated and depressed. His speech was clear and spontaneous and he was oriented times three. He denied delusions and suicidal or homicidal ideations, but endorsed chronic sleep disruption with nightmares and night sweats, obsessive ritualistic behavior (including checking the perimeter of the house and door locks) and inappropriate behavior (again discussing how he had killed his wife's dog when it snapped at him). In this respect, it was noted that he only had fair impulse control. The examiner diagnosed the Veteran with PTSD, panic attacks and depression. His assigned GAF score was 56, indicative of moderate symptoms. In April 2012, the Veteran was afforded a third VA PTSD examination, at which time, he reported that he had been experiencing chronic pain from other, unrelated medical conditions, including migraines, degenerative joint disease and a recently-implanted abdominal device. He also reported experiencing social isolation and recent bereavement, as his Vietnam war service buddy had died a week earlier. He told the examiner that he had been married to his wife for 45 years and that their relationships was "fair." He also noted that he got along adequately with his two adult children. Despite claiming that he was experiencing social isolation, he admitted that he sometimes invited members of his church congregation to come to his home for rifle shooting practice, and also enjoyed teaching children how to use high-powered weapons. In addition, he said he enjoyed hunting, fishing, mowing the lawn, gardening and doing small household repairs. While he added that he had attempted to sit closer to the front of the church with the congregation in order to please his wife, he said that it was too difficult to be around crowds and that he had had to move back to the rear of the church. He also noted that he bathed and groomed himself daily and went out to dinner with his wife about 2-3 times per month (although, he noted that he preferred sitting in the back of the restaurant where he could better observe his surroundings). Regarding his occupational life, he said that prior to his retirement in 2006, he had worked in the coal mines for 35 years, adding that his last position allowed him great autonomy and he was able get along well with his supervisors. The Veteran also reported that he was noticing less intensity in his nightmares. However, he added that he had noticed a mild increase in overall PTSD symptoms due to chronic pain since undergoing recent surgery (a February 2012 psychologist noted that the surgery reminded him of the wounds he sustained during service), as well as being reminded of aging and mortality. During the examination, the Veteran also reported that he had stopped taking his psychotropic medications due to intolerable side effects. Nonetheless, he admitted that therapy helped him "sort stuff out in [his] head," deal with his memories of Vietnam, and said that he was "significantly better," adding that his sleep difficulties and irritability were not as bad, and that his temper was a little better, as he was having slightly fewer "blow-ups." He also reported that he was able to calm down quicker since attending therapy and felt better at dealing with his PTSD symptoms. The VA examiner observed that his group therapy progress response had been good to excellent, noting that his self-reported symptomatology matched the progress notes from therapy. These symptoms included chronic sleep impairment, mild memory loss, difficulty adapting to stressful circumstances, and chronic pain from his new surgically-implanted medical device, as well as the death of his friend. During the mental status evaluation, the Veteran was noted to be properly-groomed and dressed, pleasant and oriented times three. His speech was logical and goal-directed, his affect ranged from laughing to tearful (when discussing his friend's death), his mood was fair, his recent memory was adequate, and his long-term memory was within normal limits with some minor concentration difficulties. The VA examiner diagnosed the Veteran with PTSD and assigned a GAF score of 55, suggestive of moderate symptomatology. She added that his PTSD symptoms appeared to either be the same or mildly better. In July 2012, the Veteran and his wife presented testimony during a video conference hearing before the undersigned Veterans Law Judge. The Veteran's primary contention was that the February 2012 VA examination did not adequately reflect the severity of his symptoms. In this regard, he reported that he was now experiencing nightmares every night and was seeing his therapist weekly instead of bi-weekly. His wife reported that he had frequent angry outbursts and an exaggerated startle response and also discussed in detail the incident in 2006 when the Veteran killed her dog. She further noted that she felt his symptoms had worsened in 2011 when they were experiencing severe area tornados; she added that it was at this time that his therapist increased the frequency of his visits. Moreover, despite the VA examiner's notation that she was aware that the Veteran had been unsuccessful in sitting with the congregation at his church, the Veteran said that he felt that she had not taken into account that he was only able to sit near the front of the church temporarily and had now moved back to the rear. In addition, while the Veteran reported that that the VA examiner inaccurately stated that he was having fewer nightmares, he claimed that he was simply experiencing different ones (despite admitting during the examination that his nightmares were not as intense as they had previously been). IV. Conclusion In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Board also has the responsibility to weigh the evidence, including the medical evidence, to determine where to give credit and where to withhold the same, and in so doing, the Board may accept one medical opinion and reject others, provided it offers an adequate basis for so doing. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Based on a review of the complete evidence of record, the Board concludes that the competent and probative evidence is against granting the Veteran's claim of entitlement to a disability evaluation in excess of 50 percent for PTSD. In this regard, as noted above, the Board finds that, throughout the period on appeal, the symptoms of the Veteran's PTSD have been manifested by no greater than occupational and social impairment with reduced reliability and productivity (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to chronic sleep impairment; nightmares; anger and irritability; panic attacks more than once per week; depression; mild memory and concentration loss; emotional avoidance and numbing; suspiciousness; hyperarousal; exaggerated startle response; infrequent flashbacks; and difficulty adapting to stressful circumstances (including work or a worklike setting). In this regard, the Board has carefully considered these symptoms and weighed them against the diagnostic criteria for PTSD under DC 9411. Once again, however, the Board observes that the criteria for a 70 percent disability rating include 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. In this case, however, there is no evidence of record to show, at anytime during the current appeal, that the Veteran was found to demonstrate symptoms akin to suicidal ideation, obsessional rituals that interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, spatial disorientation or neglect of personal appearance and hygiene. While it is clear that his act of killing his wife's dog demonstrated impaired impulse control, it is also clear that this was an isolated incidence and the Veteran never reported such a loss of control again. In fact, during the February 2012 VA examination, he admitted that he was experiencing fewer outbursts and "blow-ups." The Board also notes that, although the Veteran has shown some difficulty in his ability to establish and maintain effective relationships (as shown by his social isolation), he clearly has the ability to do so, as demonstrated by his now five-decades long marriage and his enjoyment of getting together with members of his church congregation for recreational activities. As noted above, 38 C.F.R. § 4.126 states that, 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. Id. (emphasis added). Finally, the Board finds that the Veteran has not been shown at anytime during the pendency of this appeal to have total occupational and social impairment due to his PTSD, and does not warrant a 100 percent rating. As noted, he has not been shown to experience persistent delusions or hallucinations, grossly inappropriate behavior or to be in persistent danger of hurting himself or others. There is no evidence of an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), or of disorientation to time or place. He has not manifested memory loss so severe as to result in the loss of names of close relatives, his own occupation or his own name. In addition to the VA examinations and outpatient treatment reports, the Board has also considered the Veteran's personal statements (as well as those of his wife) regarding the severity of his disorder. In this regard, the Board is cognizant that the Court has repeatedly held that a veteran is competent to describe symptoms of which he or she has first-hand knowledge. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). However, the Court has also held that a lay person is not competent to offer an opinion on a matter clearly requiring medical expertise, such as evaluating the complex manifestations of a psychiatric disorder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As a result, his assertions do not constitute competent medical evidence. More importantly, despite the claims of the Veteran, the medical evidence of record appears to contradict his contention that the February 2012 examination was inadequate because he claims the examiner underestimated his symptomatology. In this regard, as noted above, the VA examiner clearly took into account the Veteran's reports of not being able to sit near the front of the church, how the death of his service buddy affected him, and how he still experienced chronic pain from recent surgical procedures. Nonetheless, the Veteran himself admitted that he felt his group therapy had helped him deal with his memories of Vietnam, specifically adding that he was "significantly better," and that his chronic sleep problems and irritability were not as bad as they had previously been. While the Board has carefully reviewed and considered the Veteran's statements regarding the severity of his PTSD, the Board finds that competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. Consequently, the Board assigns limited probative value to his personal statements, in contrast to the highly probative findings of the VA examination and outpatient treatment reports. Moreover, the medical evidence largely contemplates the Veteran's descriptions of symptoms. Accordingly, and based on this evidentiary posture, the Board concludes that the symptoms resulting the Veteran's PTSD are most consistent with the currently-assigned 50 percent rating. Finally, the Board has also considered the potential application of 38 C.F.R. § 3.321(b)(1) for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (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. In this case, however, a comparison between the level of severity and symptomatology of the Veteran's condition with the established rating criteria shows that the rating criteria adequately describe the Veteran's symptomatology and disability level. The Board further observes that, even if the available schedular evaluation for the disability were inadequate (which it manifestly is not), the Veteran's disability has not been shown to cause marked interference with employment beyond that contemplated by the Schedule for Rating Disabilities; has not necessitated frequent periods of hospitalization; and has not otherwise rendered impractical the application of the regular schedular standards utilized to evaluate the severity of the disability. Thus, the Board finds that the requirements for an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). The Board concludes that the preponderance of the evidence is against the Veteran's claim. As there is not an approximate balance of evidence, the "benefit-of-the-doubt" rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990),; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ORDER Entitlement to an initial evaluation in excess of 50 percent for PTSD is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs