Citation Nr: 1311205 Decision Date: 04/04/13 Archive Date: 04/19/13 DOCKET NO. 08-14 540 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD) currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Chapman, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1965 to October 1967. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA) which, in part, granted service connection for PTSD and assigned it a 30 percent rating effective from October 19, 2006, the date of the claim. The case was remanded to the RO in September 2011 for further development. Thereafter, in August 2012, the RO increased the Veteran's rating for his service-connected PTSD o 50 percent, effective from September 27, 2011, the date of a VA examination for PTSD. While a Board hearing was scheduled per the Veteran's request, a February 2008 letter from the Veteran expressed his desire to cancel this hearing and to have his appeal decided on the evidence of record. FINDINGS OF FACT 1. Prior to September 27, 2011, the Veteran's service-connected PTSD did not cause occupational and social impairment with reduced reliability and productivity. 2. From September 27, 2011, the Veteran's PTSD does not cause occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, thinking, or mood. CONCLUSIONS OF LAW 1. Prior to September 27, 2011, the criteria for a disability rating in excess of 30 percent for PTSD were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411(2012). 2. From September 27, 2011, the criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record shows that in October 2006, May 2008, and September 2011 VCAA letters, the appellant was informed of the information and evidence necessary to warrant entitlement to the benefit sought on appeal. The appellant was also advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims' decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. In this case, the RO provided VCAA notice to the Veteran in October 2006, prior to the July 2007 rating decision. Accordingly, the requirements the Court set out in Pelegrini have been satisfied. The Board also stresses that since the issue of entitlement to a higher initial rating is a downstream issue from that of service connection (for which a VCAA letter was duly sent in October 2006), another VCAA notice is not required. VAOPGCPREC 8-2003 (Dec. 22, 2003). It appears that the United States Court of Appeals for Veterans Claims has also determined that the statutory scheme does not require another VCAA notice letter in a case such as this where the Veteran was furnished proper VCAA notice with regard to the claim of service connection itself. See Dingess v. Nicholson, 19 Vet. App. 473, 491 (2006). In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). VA also has a duty to assist a claimant under the VCAA. VA has obtained service treatment records; assisted the Veteran in obtaining evidence; examined the Veteran for PTSD in July 2007 and September 2011; and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The RO complied with the Board's September 2011 remand by obtaining a VA examination as requested and readjudicating the claim. VA has fully complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Additionally, the Board notes that it has reviewed all the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system). Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. Rather, the Board's analysis will focus specifically on the evidence pertinent to the claim, and what it shows, or fails to show, with respect to the claim. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Legal Criteria, Factual Background, and Analysis The Veteran appeals the RO's July 2007 decision denying a rating greater than 30 percent for his service-connected PTSD, and his appeal continues following the RO's grant of a 50 percent rating in August 2012, effective from September 27, 2011. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to a RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. The Veteran's PTSD is currently evaluated as 30 and 50 percent disabling during the rating period, with the change date to 50 percent being September 27, 2011. A 30 percent evaluation is warranted where there is occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The symptoms listed in VA's general rating formula for mental disorders is 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. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995); 38 C.F.R. § 4.130. According to the DSM-IV, a GAF score of 61-70 denotes some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51-60 indicates 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). A GAF score of 41-50 indicates 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). A GAF score of 31-40 indicates some impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. In March 2005 and 2006 VA treatment records, a PTSD screen and depression screen were negative. In November 2004 and 2006, the Veteran's wife submitted a statement explaining that when her husband returned from Vietnam, his behavior changed. She reported he disciplined their daughter too roughly and was too hard on the children. She stated that they had a lot of arguments and that he began to hit her. She stated that he had no patience and a very uncontrollable temper. She reported that currently, her husband is a loner and does not like to be around people. The Veteran similarly submitted a statement explaining that when he returned from war, he became more violent and mentally and physically abused his wife and children. He also stated that he prefers to be alone, enjoying hunting and fishing alone. The Veteran also reported having had suicidal thoughts. On July 2007 VA examination, the Veteran reported attending PTSD group therapy, which he believed has helped him, although he has not noticed a significant decrease in his symptoms. The Veteran described his relationship with his spouse as better than it was and stated he has a good relationship with his sons, but his relationship with his daughters is "disturbed" and he has not seen them for 8 years. Regarding social relationships, the Veteran reported that he and his wife recently became friends with another couple from church, but prior to that, they did not socialize with others. The Veteran reported enjoying fishing and hunting, and also stated that he has no history of suicide attempts. The Veteran stated that he has been violent with his wife and children, and also had a fight with a guy a couple of years ago. The Veteran stated that he has been unemployed for 2 years ever since he and his wife had to close their business due to lack of business. The examiner indicated that the Veteran's level of psychosocial adjustment was adequate. The Veteran's attitude was cooperative, friendly, relaxed, and attentive. Affect was normal, psychomotor activity, speech and thought content and processes were unremarkable, and his mood was labile. He was clean and casually dressed and was oriented to time, person, and place. The Veteran experienced no delusions or hallucinations, understood the outcome of his behavior and had average intelligence. The Veteran reported sleep impairment, stating that he sleeps probably 3 to 4 hours every night. No inappropriate behavior, obsessive behavior, panic attacks, homicidal thoughts, or suicidal thoughts were identified. The Veteran's impulse control was deemed fair, as he has aggressively acted out with family members. The Veteran was able to maintain minimum personal hygiene and has no problem with the activities of daily living. No memory problems were identified. The examiner noted impairment in social, occupational, or other important areas of functioning. As for PTSD symptoms, the Veteran reported recurrent and intrusive distressing recollections and dreams of the event. He stated that he makes an effort to avoid thoughts, feelings, or conversations associated with the trauma, and makes efforts to avoid activities, places, or people that arouse recollections of the trauma. He has markedly diminished interest or participation in significant activities. He also has difficulty falling or staying asleep, irritability or outbursts of angers, and experiences difficulty concentrating. The Veteran stated that he experiences PTSD-related symptoms once a week or so, which symptoms may last up to 2 to 3 days. The Veteran stated that he is trying to exert more control over his symptoms and that their interference with his daily functioning is minimal. He did state that being under stress usually causes him to lose his temper and he has been known to get violent when he loses his temper. Psychometric testing suggests the presence of significant psychopathology which appears to be more chronic in nature. The Veteran appeared to experience posttraumatic distress and to possess a negative self-image. Physiological signs of depression were also noted. The Veteran appeared to be quite aggressive, easily angered, and prone to physically aggressive acting out. He appeared socially detached and experienced some negative relationships. The examiner provided an Axis I diagnosis of chronic PTSD and a GAF score of 65. The examiner explained that while the Veteran was not identified upon PTSD screening, he experiences mild to moderate PTSD symptoms with labile effect. These symptoms interfere with social and occupational functioning. The Veteran's prognosis for significant therapeutic gain was guarded. VA treatment records show the Veteran regularly attended PTSD group therapy sessions in 2007 through 2009. A February 2007 psychiatry assessment provided an Axis I diagnosis of PTSD, among other things. The examiner noted that the Veteran was anxious and pleasant. His affect was flat, guarded, tearful, and depressed. His thinking was preoccupied with guilt feelings. The Veteran denied any unusual thoughts, obsessions, delusions, or hallucinations. He also denied any suicidal or homicidal ideation. He reported no nightmares now, but stated he did have them when he first returned from Vietnam. His attention span was not impaired and he was oriented to time, place, and person. His recall of recent and remote events was intact. The Veteran was capable of abstract thinking, simple calculations, and had fairly good knowledge of current events. An April 2007 social work note indicated spousal abuse by the Veteran. A May 2008 psychiatric note indicated that the Veteran felt he was doing pretty well. His affect was constricted and mood was anxious and angry with reports of episodes of losing control of his behavior. No delusions or hallucinations were noted. He reported occasional dreams regarding destruction of property or his son or daughter getting killed. He was oriented to time, person, and place with impaired recent and remote memory and poor attention span. His judgment was fair. He had no suicidal or homicidal ideas. A GAF score of 60 was provided and a PTSD screen was positive. In July 2008, a VA psychiatric note noted a GAF score of 65 and stated that the Veteran is doing much better now, with less irritability, but still having dreams and insomnia. In September 2008, a psychiatric note revealed a GAF score of 60. The examiner noted that the Veteran was still having severe episodes of anger with a tendency to get into arguments with his wife. He showed resistance to using any more medication. In July 2008, the Veteran's wife again submitted a statement stating that her husband has become more violent and she has been afraid for her safety at times. She also stated that it has been difficult for her husband to work with or be around other men because of his impatience and temper. The Veteran submitted a statement in August 2008 indicating that he no longer liked where he lived and he had been difficult for his wife to live with. He stated that he has mistreated his wife and made life miserable for those around him at times. He stated that he does receive support from his Vietnam friends. In an April 2010 suicide screen, the Veteran reported no thoughts of killing himself or wishing to die and stated that he had never attempted suicide. Further, he stated he was not feeling down, depressed, or hopeless. At this same time, he also noted a history of severe bad dreams for years, but stated he stopped taking an antidepressant and sleeping pill since this didn't seem to be a problem anymore. In an August 2011 statement, the Veteran's representative stated that the previous VA examination from July 2007 does not adequately portray the current severe disability picture of the Veteran. A new VA examination was performed in September 2011. On September 2011 VA examination, the Veteran reported loss of motivation, initial and middle insomnia, low energy, social withdrawal, loss of appetite, crying spells, and guilt. He denied depression, loss of pleasure, hypersomnia, suicidal thoughts, change of weight, feelings of worthlessness, and difficulty concentrating. The Veteran indicated experiencing anger, irritability, nightmares, repetitive thoughts or behaviors, and risk-taking. He denied anxiety/nervousness, hyperactivity, excessive sweating, stomach/bowel problems, dizziness/fainting, panic attacks, flashbacks, preoccupations, and thoughts about chronic health problems. He also denied a decreased need for sleep, periods of high energy, racing thoughts, spending sprees, hearing voices when other people are not there, getting special messages and feeling people are out to get him. He did state that in the daytime, he thinks he sees movement or flashes out of the corner of his eye, which he stated happens "quite often" but not in the last couple of weeks. The examiner identified occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. He noted a diagnosis of mild PTSD with a GAF score of 60. Symptoms that supported his finding included anxiety, suspiciousness, chronic sleep impairment, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. Further, he noted the Veteran was able to manage his financial affairs. The examiner also noted a thorough review of the Veteran's claims file and prior history. In October 2011, the Veteran was seen with complaints of trouble sleeping. It is clear that the Veteran suffers impairment due to his PTSD disability. However, after reviewing the totality of the evidence, the Board concludes that the ratings assigned by the RO for the time periods in question contemplate the degree of disability, and that the preponderance of the evidence is against higher ratings. During the period prior to September 27, 2011, the evidence paints a picture of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The reported depressed mood, sleep impairment, irritability, some social detachment, and difficulty concentrating are the types of symptoms contemplated by the 30 percent rating. The Board notes that the Veteran reported on July 2007 examination that his PTSD symptoms and their interference with his daily functioning is minimal. He stated that he only experiences PTSD-related symptoms once a week or so. The Board also notes that although the Veteran reported impaired impulse control, particularly with regard to abuse of his wife, on July 2007 examination, he noted that his relationship with his wife had improved. Further he noted a history of violence, but did not indicate that he was currently acting out and being aggressive toward others. No inappropriate behavior was identified and his impulse control was deemed fair, due to past aggressive actions toward family members. The July 2007 VA examiner provided a GAF score of 65. A May 2008 psychiatric note indicating a GAF score of 60 stated that the Veteran's mood was anxious and affect constricted, and that he experienced impaired recent and remote memory and a poor attention span; however, a July 2008 psychiatric note provided an improved GAF score of 65 and stated that the Veteran was doing much better with less irritability. The July 2007 VA examiner also noted a normal affect, a cooperate attitude, and a labile mood. The Board also acknowledges a September 2008 psychiatric note which showed a GAF score of 60 and noted the Veteran was still having episodes of anger. However, in all of these assessments, including the July 2007 VA examination, the examiners seem to be denoting mild to possibly moderate symptoms, as reflected by the GAF scores provided. A GAF score of 65 is in the mid-range of the category denoting mild symptoms, while a GAF score of 60 is at the upper range of the category denoting moderate symptoms. Thus, even though the Veteran was exhibiting impaired impulse control and some anger episodes, none of the examiners seemed to indicate that the Veteran's symptomatology was anything more than mild, or slightly moderate. Moreover, the evidence during this period shows that the Veteran was generally functioning satisfactorily. He reported having friends, having a good relationship with his sons and an improving relationship with his wife. His behavior was generally routine as was his self-care and conversations. The Veteran admitted to being unemployed, although admitted this was due to lack of business and not his PTSD. He stated that he had friends from Vietnam and that he and his wife now were friends with another couple from church. His speech was normal and he was oriented to time, place, and person without experiencing any panic attacks or delusions, hallucinations, or suicidal or homicidal ideation. He did not experience difficulty in understanding complex commands or exhibit circumstantial or stereotyped speech. There is also no evidence of impaired abstract thinking or reduced reliability. The Board has considered the Veteran's and his wife's statements that he was changed after returning from Vietnam and that his irritability and anger toward others was a result of his PTSD. The Board does not doubt that the PTSD had some impact on the Veteran's impulse control, but the totality of the evidence more nearly approximates the criteria for a rating of 30 percent and does not show such impairment to more nearly approximate the criteria for a rating in excess of 30 percent prior to September 27, 2011. The RO increased the PTSD rating to 50 percent, effective from the date of VA examination on September 27, 2011. Although generally functioning satisfactorily, the September 2011 examiner noted anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances. In reviewing this examination report and comparing it to previous reports, it appears that the RO viewed the continued sleep impairment, impaired judgment, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships may have caused the overall disability picture to more nearly approximate the criteria for such higher rating. However, the Board is compelled to conclude that the preponderance of the evidence is against a rating in excess of the 50 percent assigned by the RO from September 27, 2011. First, the Veteran does not exhibit difficulty in understanding complex commands, impairment of long term memory, impaired abstract thinking, or disturbances of mood. Although the Veteran reported a loss of motivation, he denied depression, difficulty concentrating, loss of pleasure, hypersomnia, suicidal thoughts, and feelings of worthlessness (among other things). Secondly, the September 2011 VA examiner noted a GAF score of 60. As stated previously, this GAF score is at the upper end of the range of scores denoting moderate symptomatology. Further, this score does not reflect a marked decrease in symptomatology, as the Veteran had previously been provided with a GAF score of 60 (but no lower). Finally, the Veteran does not have occupational and social impairment with deficiencies in most areas due to the types of symptoms contemplated for the next higher rating of 70 percent. He specifically denied suicidal ideation and obsessional rituals which interfere with routine activities. He did not exhibit speech intermittently illogical, obscure or irrelevant; nor did he exhibit near continuous panic or depression. In fact, on July 2007 VA examination, the Veteran denied depression. The Veteran continues to maintain his ability to function independently (he can manage his finances and is well-groomed with no limitation of functions in daily activities). The records never indicate that the Veteran neglected his personal appearance and hygiene. Further, although the Veteran had difficulty in establishing and maintaining effective work and social relationships, he did not exhibit an inability to establish and maintain such relationships. As for the Veteran's and his representative's arguments that his PTSD symptoms seem to support a higher rating than what has already been provided, the discussion above shows that no more than a 30 percent rating prior to, and a 50 percent rating from September 27, 2011 is warranted. The Board notes that the examiners who examined him are professionals who provided objective evidence concerning his disability picture as well as opinions as to his GAF and the amount of impairment caused by the Veteran's PTSD, after considering his history and examining him. Therefore, the information in the examination reports is deemed most persuasive. Prejean v. West, 13 Vet. App. 444 (2000 (factors for determining probative value of medical opinions include their thoroughness and detail, whether they discussed why contrary opinions were not persuasive, and the opinion-writer's access to relevant records). Although certain symptoms listed for various ratings under the diagnostic criteria have been occasionally demonstrated, it is the total disability picture which the Board looks to. The Board again stresses to the Veteran that it does not doubt the fact that the PTSD results in significant impairment. However, the Board is bound to apply the regulatory rating criteria set forth earlier in this decision. The RO has assigned a 30 percent rating prior to September 27, 2011, and a 50 percent rating from that date on. The evidence shows that the Veteran's symptoms and resulting impairment are fully contemplated by these ratings during these time periods. The preponderance of the evidence is against a finding that higher ratings are warranted. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 4.3, but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. Should the Veteran's disability increase in severity in the future, he may always advance a claim for an increased rating. Extraschedular Consideration The potential application of various provisions of Title 38 of the Code of Federal Regulations has also been considered, but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). In this case, there are no exceptional or unusual factors with regard to the Veteran's disability on appeal. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe his disability level and symptomatology and provides for more severe symptoms than shown by the evidence during the period in question; thus, her disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Hence, referral for extraschedular consideration is not warranted. Further, there is no evidence to indicate that the Veteran is unable to maintain full time employment due to service-connected disability. Thus, the issue of entitlement to total disability based upon individual unemployability (TDIU) is not for present consideration. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER The appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs