Citation Nr: 1309583 Decision Date: 03/21/13 Archive Date: 04/01/13 DOCKET NO. 06-10 758A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to an evaluation in excess of 50 percent for post traumatic stress disorder (PTSD) with major depressive disorder (MDD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran appears to have had active service from June 1977 until January 1983 and from September 1983 to January 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. By that rating action, the RO assigned a 30 percent disability rating to the service-connected PTSD with MDD, effective October 19, 2004--the date of a VA treatment report reflecting an increased in severity of this disability and accepted as an informal claim for increased compensation. The Veteran appealed the RO's assignment of a 30 percent disability rating to the above-cited disability to the Board. In December 2006 and July 2009, the Veteran testified before a Decision Review Officer (DRO) and the undersigned at hearings conducted at the above-cited RO. Copies of the hearing transcripts have been associated with the claims files. In a September 2011 decision, the Board, in part, granted a disability rating of 50 percent to the service-connected PTSD with MDD. In granting the 50 percent rating, the Board also determined that the criteria for a 70 percent rating for the service-connected PTSD with MDD had not been met. (See September 2011 Board decision, page (pg.) 20)). The Veteran appealed the Board's denial of a 70 percent rating for the above-cited disability to the United States Court of Appeals for Veterans Claims (CAVC). In a January 2012 Order, the CAVC vacated the Board's decision to the extent that it denied a rating in excess of 50 percent for the service-connected PTSD with MDD, and remanded the appeal to the Board for development consistent the Joint Motion for Remand (JMR) agreed to by the Secretary of Veterans Affairs and the Veteran's Counsel (Parties). FINDING OF FACT For the entire appeal period, the evidence reflects that the Veteran's PTSD with MDD has been productive of occupational and social impairment with deficiencies in most areas and an inability to establish and maintain effective relationships but without evidence of total occupational and social impairment. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for a schedular evaluation of 70 percent for service-connected PTSD with MDD have been met for the entirety of the appeal period extending from October 19, 2004. 38 U.S.C.A. §§ 1155, 5103, 5013A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 4.1 , 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist Before addressing the merits of the issue on appeal, VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via post-adjudication letters, dated in July 2008 and December 2009, of how VA determines disability ratings and effective dates, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. These letters accordingly addressed all notice elements. None of the above-cited letters predated the appealed June 2005 rating action. However, as the claim was followed by readjudication of the appeal in a March 2011 supplemental statement of the case, the timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication was cured. Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34. Nothing more was required. The Board also notes that the Veteran has actively participated in the processing of his appeal, and his statements submitted in support of his claim, to include from his accredited representative and spouse have indicated familiarity with the requirements for the benefits sought on appeal. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (VA can demonstrate that a notice defect is not prejudicial if it can be demonstrated ... that any defect in notice was cured by actual knowledge on the part of the appellant that certain evidence (i.e., the missing information or evidence needed to substantiate the claim) was required and that the appellant should have provided it.); see also Overton v. Nicholson, 20 Vet. App. 427 (2006). In addition, the Board notes that in Vazquez-Flores, 22 Vet. App. 37 (2008), the Court held that in increased evaluation claims, VA must inform the claimant that, in order to substantiate a claim, he or she must provide (or ask the VA to obtain) medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that such worsening has on the claimant's employment and daily life. Further, if the diagnostic code under which the claimant is currently rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by providing the evidence described above (such as a specific measurement or test result), then VA must give at least general notice of that requirement. Additionally, VA must inform the Veteran that if he or she is assigned a higher rating, that rating will be determined by applying relevant diagnostic codes, which generally provide for disability ratings between 0 and 100 percent, based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. The notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Id. at 43. However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) issued a decision vacating and remanding the above-summarized decision of the Court. See Vazquez- Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Specifically, the Federal Circuit held that only "generic notice," and not "Veteran-specific" notice is required under 38 U.S.C.A. § 5103(a) in response to the "particular type of claim." With respect to a claim for an increased rating, such notice does not need to inform the claimant of the need to submit evidence concerning the effect of a service- connected disability on his or her "daily life" because only the average loss of earning capacity, and not impact on daily life, is subject to compensation under 38 U.S.C. § 1155. Accordingly, the Federal Circuit vacated the decision of the Court insofar as it requires VA to notify a Veteran of alternative diagnostic codes or potential "daily life" evidence. Id. Therefore, in the instant case, there has been an intervening change in the law with respect to the required VCAA notice in an increased rating claim. The Federal Circuit recognizes three exceptions to the law of the case doctrine, to include when the controlling authority has since made a contrary decision of law. See Chisem v. Brown, 8 Vet. App. 374 (1995); see also Leopoldo v. Brown, 9 Vet. App. 33 (1996) (per curiam). As such, the heightened VCAA notice requirements under Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), are no longer required. VA has also fulfilled its duty to assist the Veteran with respect to his increased evaluation claim decided herein. The Veteran's service treatment records (STRs) and post-service private and VA treatment and examination reports have been associated with the claims files. VA examined the Veteran to determine the current (then) severity of his PTSD, most recently in May 2010. Copies of the VA examination reports are contained in the claims files. The VA examiners recorded the Veteran's subjective complaints and identified the nature and severity of his PTSD with MDD. The findings contained in these examination reports are adequate for VA adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran was provided an opportunity to set forth his contentions during a hearing in July 2009 before the undersigned. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the July 2009 hearing, the undersigned identified one of the issues on appeal as entitlement to an increased rating for PTSD with MDD, then rated as 30 percent disabling. (See Transcript (T.) at pg. 2)). The undersigned noted that the Veteran had sought psychiatric treatment from a private clinician since 2008 and acknowledged that those records had been associated with the record. (T. at pg. 12). Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available. The Board finds that no further assistance is warranted with respect to the above-cited increased evaluation claim. VA may proceed with the consideration of this claim in the analysis below. II. Laws and Regulations General criteria The Board has thoroughly reviewed all of the evidence in the Veteran's claims folders. Although the Board has an obligation to provide reasons and bases supporting its 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 increased evaluation claims. 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). Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, such as here, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, 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. 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. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). As will be demonstrated through the analysis below, the Veteran's PTSD with MDD symptoms have remained constant throughout the course of the period on appeal as demonstrated by similar findings on VA examinations in 2005, 2008 and 2010. As such, staged ratings are not warranted for the Veteran's PTSD with MDD. Hart, supra. 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. See 38 C.F.R. § 4.7. Psychiatric rating criteria The Veteran's service-connected PTSD with MDD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. The psychiatric symptoms listed in the rating criteria below are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the general rating formula for mental disorders, a 50 percent evaluation envisions 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. A 70 percent evaluation envisions 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); and an inability to establish and maintain effective relationships. A 100 percent schedular evaluation is warranted when 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 of names of close relatives, own occupation, or own name. According to the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM- IV), which VA has adopted, under 38 C.F.R. §§ 4.125 and 4.130, a Global Assessment of Functioning (GAF) score of 61 to 70 denotes mild symptoms or some difficulty in social and occupational functioning. A GAF score of 51 to 60 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates serious symptoms or a serious impairment in social, occupational, or school functioning. 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). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Carpenter v. Brown , 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). III. Procedural and Factual Background The Veteran seeks a disability rating in excess of 50 percent for his PTSD with MDD. He maintains that symptoms of his PTSD with MDD have caused significant social and industrial impairment in his employment; thus, a 70 percent disability rating is warranted. By an April 1999 rating action, the RO granted service connection for depression; an initial 10 percent evaluation was assigned, effective from June 1998. In October 2004, the Veteran filed an increased rating claim for depression as well as claim for service connection for PTSD. In support of the claim, a lay statement was provided by the Veteran's spouse in October 2004. She described symptoms the Veteran's symptoms of isolation, withdrawal and nightmares, which she attributed to his depression/PTSD. Upon VA mental health evaluation of October 2004, the Veteran gave a history of depression secondary to headaches, beginning in 1988 or 1989. He identified symptoms including: depression; isolation; crying; irritability and sleep impairment. He denied having suicidal or homicidal ideation. Preoccupation with and flashbacks of an event in service during which the Veteran was hit over the head with a beer bottle at an employee picnic, causing the onset of his chronic headaches, was noted. The report indicated that the Veteran was married, in a good relationship, and had 3 children. Mood disorder secondary to a medical disorder, and noncombat related PTSD were diagnosed. (See VA treatment report, dated October 19, 2004). A January 2005 VA PTSD intake form reflects that the Veteran's complaints included: intrusive thoughts, insomnia, social isolation, depression, and anger problems, as well as re-experiencing. The report reflected that the Veteran was married and worked for a VA Medical Center (VAMC). It was noted that results from an assessment revealed that the Veteran was a highly distressed individual who lacked the resources to develop and maintain alternative coping strategies. His primary problems reportedly involved isolation, as well as anger and aggressive behavior, as demonstrated by numerous aggressive outbursts against his wife. The examiner noted that the Veteran's problems with intrusive memories had caused him to develop problems with irritability and working with others. It was also noted that the Veteran's avoidance symptoms had negatively impacted his relationships as evidence by his "emotional numbing." The Veteran was referred for treatment through a trauma recovery program. A VA examination was conducted in March 2005. The examiner related that the Veteran had been married for 7 years, and was employed at a VA Medical Center (VAMC), where he had worked for 22 years. He reported that his children had difficulty understanding the problems caused by his headaches and psychiatric disorder and were disappointed that he was not more participatory with them. The Veteran's reported symptoms included: sleep impairment (due to shift work), poor appetite, no hobbies, and reduced concentration. He denied having suicidal ideation. On mental status examination, the Veteran was well-oriented and appropriately groomed. Thought content and processes were within normal limits. There was no evidence of delusions or hallucination and the Veteran denied having suicidal or homicidal ideation. Speech was normal and there was no indication of gross memory loss or impairment. The examiner mentioned that the Veteran had no meaningful social relationships and no longer engaged in any of the recreational pursuits that he used to enjoy. Recurrent, moderate major depressive disorder was diagnosed and a Global Assessment of Functioning (GAF) score of 55 was assigned. In May 2005, a VA PTSD examination was conducted by the examiner who had examined the Veteran in March 2005. It was noted that the Veteran was still employed, but that his work performance was up and down and he was missing a great deal of work, using up almost all of his leave. The Veteran continued to report that he had no friends, no meaningful hobbies, and was isolated. He also acknowledged having symptoms of hypervigilence, irritability, and poor concentration (primarily attributed to headaches). On mental status examination, the Veteran was well-oriented and appropriately groomed. Thought content and processes were within normal limits. There was no evidence of delusions or hallucination and the Veteran denied having suicidal or homicidal ideation. Speech was normal and there was no indication of gross memory loss or impairment. The examiner mentioned that the Veteran had no meaningful social relationships and no longer engaged in any of the recreational pursuits that he used to enjoy. The examiner indicated that the Veteran used his work at the VA as a coping mechanism to deal with his symptoms. The examiner concluded that the criteria for a diagnosis of PTSD were met and explained that the Veteran had depression related to a chronic medical condition (headaches), and PTSD related to an assault in service. A GAF score of 52 was assigned. By rating action of June 2005 (on appeal), service connection was granted for PTSD and this condition was associated with service-connected depression, for which combined 30 percent evaluation was assigned, effective from October 2004. A VA record dated in March 2006 indicates that the Veteran experienced a flare-up of depressive and PTSD symptoms while working at the VAMC during Hurricane Katrina. The entry indicated that the Veteran was having intrusive thoughts of the smells of human feces, filth and death, and it was noted that he had worked in the emergency room without light and electricity, doing 16 to 20 hour shifts. It was further noted that the Veteran was screaming in his sleep, having fits of rage with temper flare-ups and screaming at his wife, and experiencing nightmares. The file contains an August 2006 statement from a VA staff psychiatrist explaining that the events of Hurricane Katrina had caused an exacerbation of the Veteran's PTSD and depressive conditions, and had impaired his ability to function socially and in the workplace. Symptoms of anger, rage, flashbacks, intrusive thoughts and a recent panic attack were documented. The psychiatrist stated that the PTSD flare-up had caused the Veteran to take a leave of absence from VA and it was noted that he continued to be profoundly depressed, with anergia, anhedonia and transient suicidal thoughts. The psychiatrist indicated that due to the severity of the PTSD and depression, which were affecting the Veteran's ability to work, an increased evaluation should be considered. The psychiatrist added that he had encouraged the Veteran to seek early retirement, as the stress of work was having a negative impact on his mental health, and felt that the Veteran should be considered unemployable due to PTSD and depression. The Veteran presented testimony at a hearing held at the RO in December 2006. He explained that he experienced an exacerbation of PTSD while working at the VAMC emergency room during Hurricane Katrina. A VA PTSD examination was conducted in April 2008 and the claims file was reviewed. It was noted that the Veteran was still working for the VAMC and was still reliving events which occurred during Hurricane Katrina. He complained of nightmares and night sweats, sleep impairment, feelings of irritability and anger with two to three episodes of angry outbursts a week - at home but not at work, and significant absenteeism. He also described having symptoms of forgetfulness and lack of concentration and it was reported that he was not interacting with his wife and children. An April 2008 VA mental status examination revealed that the Veteran was well-oriented and appropriately groomed. His mood was depressed. The Veteran's memory functions were grossly intact. His speech was normal. The Veteran denied having suicidal or homicidal ideation. He noted improved sleep with medications. Thought content and processes were described as over-focused on Hurricane Katrina. Judgment was assessed as functional with marginal insight. Chronic PTSD and major depressive disorder were diagnosed and GAF scores of 52 (PTSD) and 65 (depression) were assigned. The examiner explained that PTSD was impacting the Veteran's psychosocial functioning and quality of life to a moderate degree. It was noted that the Veteran had a long and consistent work history with VA, despite the fact that he occasionally needed to take time off. While the VA examiner noted that the Veteran denied any significant effect of his symptoms on his employment at that time. However, the VA examiner also noted the Veteran had switched his place of employment to a small outpatient setting from an emergency room at a large VA Medical Center, which tended to exacerbate his symptoms. The Veteran presented testimony at a travel Board hearing held at the RO in July 2009. He explained that he experienced an exacerbation of PTSD while working at the VAMC emergency room during Hurricane Katrina and stated that he had worked for VA for 28 years. In September and December 2009, second and third medical statements were offered by the Veteran's treating psychiatrist, Dr. W., in support of an increased rating to 70 percent. The psychiatrist noted that the Veteran's PTSD and depressive conditions had been severely disabling at work and resulted in the use of a large amount of leave since 2006. It was also reported that the Veteran was unable to attend work training in New Orleans due to panic attacks and intrusive memories of Hurricane Katrina. The psychiatrist mentioned that the Veteran's conditions had caused profound social impairment and marital trouble, with manifestations of explosive temper, an episode of destruction of furniture (2008), violent and homicidal thoughts, as well as severe social withdrawal and emotional numbing. The psychiatrist summarized that the Veteran's conditions were manifested by occupational and social impairment with deficiencies in most areas, including work, family, relations and mood, as well as difficulty in adapting to a stressful circumstance at work and an inability to establish and maintain effective relationships. The most recent VA psychiatric examination was conducted in May 2010 and the claims filed were reviewed. The examiner noted that the Veteran was still employed with VA. He denied having any disciplinary problems and reported that he was doing well on the job. The Veteran complained of problems with concentration, numbness and detachment. He also indicated that he was having problems getting along with his family members and did not like to go out. Mental status examination revealed that the Veteran was well-oriented and appropriately groomed. The Veteran's speech was normal. His mood was described as down. His affect was tearful. The Veteran denied having suicidal or homicidal ideation. Thought process and content was within normal limits. The Veteran complained of concentration problems which were not evident on examination. Judgment was described as functional. The examiner noted that the Veteran did not report having nightmares on examination was sleeping better with medication. The examiner was unable to reconcile the difference in GAF scores made in 2008, but observed that the Veteran was clearly not having significant impairment. The VA examiner observed that Dr. E. W.'s statements detailed the Veteran's occupational impairment, but noted that the Veteran himself reported that work was the one place where he felt comfortable and successful. The examiner noted that Dr. E. W.'s assessment could be explained as possible over-interpreting the Veteran's symptoms. The VA examiner agreed with Dr. E. W. to the effect that the Veteran's depressive symptoms were part of his PTSD and not a separate disorder. The VA examiner indicated that on testing, the Veteran acknowledged having mild symptoms of anxiety, depression, intrusive experiences and avoidance. Chronic PTSD was diagnosed and a GAF score of 55 was assigned. The examiner further noted that the Veteran's significant impairment was social, manifested by isolation. As was noted in the Introduction section of this decision, the Board rendered a decision in September 2011 decision increasing the Veteran's disability rating from 30 percent to 50 percent for his service-connected PTSD with MDD. In granting the 50 percent rating the Board also denied a rating in excess of 50 percent. The Veteran appealed the Board's denial of the next higher 70 percent rating for the above-cited disability to the United States Court of Appeals for Veterans Claims (CAVC). In the January 2012 JMR and CAVC Order, the Board's decision was vacated to the extent that it denied a rating in excess of 50 percent for the service-connected PTSD with MDD. The JMR cited to evidence which the Parties indicate are consistent with the criteria for the assignment of a 70 percent rating. In view of the JMRs findings and for the reasons set forth below, the Board affords the Veteran all reasonable doubt and awards a 70 percent disability rating for service-connected PTSD with MDD since October 19, 2004. IV. Legal Analysis The Board finds that the competent evidence of record supports an award of a 70 percent disability rating for PTSD with MDD for the entire appeal period, beginning on October 19, 2004. The Board finds that in affording the Veteran all reasonable doubt in his favor, the evidence as a whole in at least in equipoise that from as early as mid-October 2004, the Veteran, although married to his spouse, has exhibited significant social impairment, primarily manifested by social isolation, and exhibited impaired impulse control. Aside from an April 2008 VA examiner, who found the Veteran's PTSD with MDD symptoms to have had a moderate impact on his social functioning, the remaining VA and private examiners of record have uniformly concluded that these symptoms have caused him to develop profound and significant social impairment. For example, an October 2004 VA treatment report reflects that the Veteran socially isolated himself. A January 2005 VA examiner indicated that the Veteran's avoidance symptoms had negatively impacted his relationships as evidence by his "emotional numbing." A March 2006 VA examiner indicated that one of the Veteran's primary problems was anger and aggressive outburst towards his spouse as exhibited by his fits of rage with temper flare-ups that involved screaming at his spouse, respectively. (See January 2005 and March 2006 VA intake and treatment reports, respectively). VA examiners in March and May 2005, reports, September and December 2009 reports, authored by Dr. E. W., and a May 2010 VA examiner have each found the Veteran's PTSD with MDD symptoms to have caused him not to have any meaningful social or relationships, or to have participated in any recreational pursuits (March and May 2005 VA examination reports); to have caused profound social impairment and marital trouble with manifestations of an explosive temper (September and December 2009 reports, authored by Dr. E. W.); and to have caused significant social isolation (May 2010 VA examiner). Thus, the evidence is at least in equipoise that from as early as mid-October 2004, the Veteran, although married to his spouse, has exhibited significant social impairment, primarily manifested by social isolation, and impaired impulse control. With regards to industrial impairment, evidence in support of the Veteran's appeal, includes September and December 2009 statements, authored by his treating psychiatrist, Dr. E. W. Dr. E. W. concluded that the Veteran's PTSD and depressive conditions had been severely disabling at his work and had resulted in him having to use large amounts of leave since 2006. Dr. E. W. also indicated that the Veteran had been unable to attend work training in New Orleans due to panic attacks and intrusive memories of Hurricane Katrina. Dr. E. W.'s findings are supported by an August 2006 VA psychiatrist, who concluded that the events of Hurricane Katrina had caused an exacerbation of the Veteran's PTSD and depressive condition to the point that they had impaired his ability to function socially in the workplace. Conversely, VA examiners in April 2008 and May 2010, concluded that Veteran had a long work history with VA, despite the fact that he occasionally need to take time off from work, and that Dr. E. W., had possibly over-interpreted his symptoms, respectively. (See April 2008 and May 2010 VA PTSD examination reports). Yet, the April 2008 VA examiner also opined that the Veteran's PTSD symptoms had been ameliorated after he had switched his employment from a large VAMC to a small VA outpatient center. Thus, the April 2008 VA examiner's comment suggests that the Veteran's was likely limited in his ability to work outside of a sheltered environment, such as that provided by a small VA outpatient center, due to his PTSD with MDD alone. In addition, the April 2008 and May 2010 VA examiners' conclusions are contradicted by January and May 2005 VA examiners. These examiners opined that the Veteran's problems with intrusive memories had caused him to develop problems with irritability and working with others, as well as fluctuations in his work performance and extensive absenteeism that had resulted in him having to use all of his leave, respectively. (See January and May 2005 VA intake and PTSD examination reports, respectively). Affording the Veteran all reasonable doubt by considering the evidence in a light most favorable to the Veteran, the Board finds that the evidence of record is in equipoise that the symptoms stemming from the Veteran's PTSD with MDD had caused him to have difficulty adapting to his work at the VA as evidenced by fluctuating work performance, extensive absenteeism that resulted him having to use much of his leave, as well as social impairment in the workplace. In view of the foregoing, the Board finds that the Veteran's symptoms associated with service-connected PTSD with MDD is sufficient to warrant a 70 percent disability rating for the appeal period in light of occupational impairment and work deficiencies and significant social impairment, primarily manifested by social isolation, for the entire appeal period, beginning on October 19, 2004. The Board has considered whether the assignment of the next higher rating of 100 percent warranted. However, the evidence does not indicate that the Veteran suffers significantly from any of the symptoms that may be associated with total occupational and social impairment. While the Veteran has exhibited impaired impulse control, he has remained employed with the VA and married to his spouse. Aside from impaired impulse control and an isolated reporting of homicidal thoughts in 2009, the Veteran has not exhibited any of the other objective symptoms that may be associated with the symptoms listed in the criteria for a 100 percent evaluation. Specifically, there is no evidence of the Veteran exhibiting behavior of having a distorted view of reality, such as: persistent delusions or hallucinations; gross impairment in thought processes or communication; inability to maintain minimal personal hygiene; disorientation to time, place, or own person; and is otherwise not shown to be a danger to himself or others. Rather, in view of his ability to engage in behavior acceptable to maintain a full-time job and at least minimal activities of daily living, the Veteran is far more appropriately evaluated at the 70 percent rate for the appeal period. Given the consistency of the findings as to severity during the pendency of this appeal, there is no basis for "staging" this evaluation pursuant to Hart. V. TDIU Consideration In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on unemployability due to service- connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. The record reflects that throughout the appeal, the Veteran has remained full-time by VA. Accordingly, the Board concludes that a claim for TDIU has not been raised by either the Veteran or the record. VI. Extraschedular Consideration In evaluating the Veteran's claim for an increased rating for the service-connected PTSD with MDD, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. 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). According to the regulation, an extraschedular disability rating is warranted based 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). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. 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 first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the 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 evaluation for the service-connected PTSD and MDD is inadequate. A comparison between the level of severity and symptomatology of this disability, with the established criteria found in the rating schedule, shows that the rating criteria reasonably describe the Veteran's PTSD with MDD, as discussed above. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required any hospitalizations for his PTSD with MDD. There is no persuasive evidence in the record to indicate that the service-connected PTSD with MDD would cause any impairment with employment over and above that which is already contemplated in the assigned schedular rating. As noted above, the Veteran is a full-time VA employee. 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. Further, 38 C.F.R. § 4.1 (2012) specifically sets out that "[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." Factors such as requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the evaluations assigned herein. What the evidence does not demonstrate in this case is that the manifestations of the Veteran's service-connected PTSD with MDD have resulted in unusual disability or impairment that has rendered the criteria and/or degrees of disabilities contemplated in the Schedule impractical or inadequate. Accordingly, consideration of 38 C.F.R. § 3.321(b)(1) is not warranted in this case. ORDER As of October 19, 2004, a 70 percent disability rating is granted for PTSD with MDD, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs