Citation Nr: 1311536 Decision Date: 04/08/13 Archive Date: 04/19/13 DOCKET NO. 10-45 521 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to a rating in excess of 50 percent for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran had active military service from September 1966 to August 1971. This appeal comes to the Board of Veterans' Appeals (Board) from a December 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. In addition to appealing the RO's decision in his claim for an increased rating for PTSD, the Veteran also appealed his claim for service connection for tinnitus. However, the RO granted service connection for tinnitus in an April 2011 rating decision; therefore, the Board finds that issue is no longer in appellate status. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDING OF FACT The competent evidence shows that the Veteran's service-connected PTSD is manifested by occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for an increased rating greater than 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1110, 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.21, 4.130, Diagnostic Code (DC) 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: 1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and 2) the appeal is readjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in August 2009. In the letter, the RO informed the Veteran of what evidence was required to substantiate the claim for service connection and of the Veteran's and VA's respective duties for obtaining evidence. In the letter the RO also provided notice with regard to how VA assigns disability ratings and effective dates in the event that service connection is established. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). The Board finds that all necessary development has been accomplished. The RO has obtained the Veteran's service treatment records and VA treatment records. The Veteran has also submitted statements in support of his claim. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The record reflects that the Veteran started receiving Social Security Administration (SSA) benefits after he turned 62 and retired. Even though the Veteran has reported that what prompted him to retire was an explosion at work that exacerbated his PTSD symptoms, the Veteran does not contend, nor does the record suggest that the Veteran's receipt of SSA benefits had anything to do with his PTSD disability, but rather his retirement based on age. In Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009), however, the Federal Circuit acknowledged that VA's duty to assist was limited to obtaining relevant SSA records. The Federal Circuit rejected the appellant's argument in Golz that SSA records are always relevant and VA always is required to obtain them. The Federal Circuit then defined relevant records as "those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the Veteran's claim." Id. at 1321. The Federal Circuit also stated, "Not all medical records for a Veteran will have a reasonable possibility of aiding in the substantiation of a VA disability claim." Id. The Federal Circuit concluded in Golz, "There must be specific reason to believe these records may give rise to pertinent information to conclude that they are relevant." Id. at 1323. The Board has determined that with regard to the PTSD claim on appeal the Veteran's social security records are not relevant and thus the Board will proceed with a decision on the merits. The Veteran was afforded VA medical examinations in November 2009 and January 2011. The examiners, medical professionals, obtained an accurate history and listened to the Veteran's assertions. The examiners provided the Board with sufficient information to decide the issue on appeal. Therefore, the Board finds that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. 183. Increased Rating The RO granted service connection for PTSD in January 2006 and assigned a 50 percent rating. The Veteran filed his present increased rating claim in July 2009. He contends that his service-connected PTSD is more disabling than currently evaluated. The Veteran's representative submitted argument in April 2012 that the Veteran's symptoms more closely approximated a 70 percent rating, as the record demonstrated that his symptoms were severe and that his PTSD symptoms had caused him to quit his job in 2002. His representative also argued that the Veteran had entertained regular suicidal thoughts and had failed to establish and maintain social connections with friends and his son. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The following discussion addresses the Veteran's levels of disability from the time the increased rating claim was filed in July 2009. Francisco, 7 Vet. App. 55; Hart, 21 Vet. App. 505. The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C.A. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that "the tie goes to the runner." Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Notably, the benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. The Veteran's PTSD is currently evaluated as 50 percent disabling, effective May 28, 2004, under the criteria of Diagnostic Code 9411. See 38 C.F.R. § 4.132. A 50 percent rating contemplates 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A next higher 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); and inability to establish and maintain effective relationships. Id. 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; and memory loss for names of close relatives, own occupation, or own name. Id. Symptoms listed in VA's general rating formula for mental disorders 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. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). 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 the basis of social impairment. 38 C.F.R. § 4.126(b). In this case, the Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. After a careful review of the record and for reasons and bases expressed immediately below, the Board finds that the medical records as a whole do not support a greater than 50 percent rating for the Veteran's PTSD. The Veteran was afforded a VA psychological examination in November 2009. The Veteran reported he is married and described his relationship as "tolerating one another." He said he gets along well with his two children. He reported having friends with whom he hunts, plays golf, fishes, and occasionally goes out to eat. He said he is able to go to family functions. He does not watch the news and does not like movies with military themes. The examiner noted his general appearance was appropriate, his attitude cooperative, and his affect appropriate. He described the Veteran's speech as spontaneous, clear, coherent, irrelevant, and obscure. He described his mood as anxious, expansive, and dysphoric. He was oriented. He noted the Veteran easily became tangential and over-expansive in his conversation. He found his thought process to be rambling with an overabundance of ideas, looseness of associations, and tangentiality. The Veteran reported having nightmares several nights a week and not sleeping more than four to six straight hours. He recalled that he had in the past dove for cover in his sleep due to feeling he was being attacked. The Veteran reported he always keeps a weapon near him. He did not report homicidal or suicidal thoughts and the examiner stated that he had good impulse control. He also did not report panic attacks. The examiner found the Veteran's immediate memory was impaired. The Veteran reported recurrent and intrusive distressing recollections and trying to avoid activities, places, or people that aroused recollections of the trauma. He reported markedly diminished interest or participation in significant activities and feeling detachment or estrangement from others. The Veteran also reported irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated started response. The examiner found the Veteran had some impaired social/family relationships and was somewhat socially withdrawn. The examiner stated the Veteran reported he is careful around family at times when he is thinking about Vietnam due to agitation. The Veteran reported he quit working in 2002 due to his age/duration of work and because he had a flashback after an explosion at work. The examiner assigned a GAF of 61. He opined that the Veteran's PTSD symptoms are not severe enough to interfere with occupational and social functioning. In October 2010, the Veteran's primary care provider at the VA wrote in a letter to the VA that the Veteran has "severe PTSD" and has been "plagued with intense combat nightmares, flashbacks, hypervigilance and admits to a history of suicidal thoughts." She stated the he has coped with the support of his family but retired in his mid-50s because explosions at work exacerbated his symptoms. The Veteran saw a VA psychologist twice in October 2010, reporting increased PTSD symptoms over the past year. He reported he was becoming more withdrawn and experiencing increased road range. He also reported losing his temper with his children. He was becoming more of a recluse and his appearance was "on the decline." At his second visit that month, the Veteran stated that a black eye he had was from falling out of bed while having a dream about jumping into a fox hole. His psychologist noted that the Veteran's reports would suggest an exacerbation of his PTSD. The Veteran also reported at an October 2010 VA medical appointment that he had smashed window during a nightmare. The Veteran was afforded another VA examination in January 2011. He continued to report sleeping no more than 6 hours per night and indicated that his sleep was very restless, including thrashing about. He reported nightmares once a week. He reported he drinks alcohol every day starting in the afternoon and his wife says he drinks too much. The Veteran reported he does not like being around other people and spends most of his time with his wife. He does not go to the movies because he does not like the noise. He reported he enjoys playing golf and said he plays a few times per month. He said it is not easy for him to make friends. He indicated he has a few friends and plays golf in a league. He quit going to the Veterans of Foreign Wars (VFW) hall because he did not want to be around the other veterans. He described his relationship with his son as "strained" but said he maintains frequent contact. The Veteran acknowledged experiencing flashbacks a few times per month. He avoids watching the news. He said he has suicidal ideations about twice a month. Since his last VA examination he said he has thought about driving off the road, but stops and asks himself what he is doing and does not go through with it. The examiner found the Veteran to be alert and oriented. He was unshaven but otherwise adequately groomed, had adequate eye contact, fair insight and judgment, appropriate impulse control, and intact memory. His mood was depressed and the examiner noted he was circumstantial at times but easily redirected. The examiner assigned a GAF of 55. A veteran's level of social and occupational functioning is the crux of any rating assigned under the General Rating Formula. In this case, the Board finds the Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity, and that the currently assigned 50 percent rating correctly contemplates his level of functioning. Socially, although the Veteran reports he does not like to be around people and it is not easy for him to make friends, he has also described engaging in a number of social activities. For example, as of January 2011 he continued to report playing golf in a league. He also stated that he has a few friends, although he indicated he spends most of his time with his wife. He also noted that he had not been involved with the VFW recently. He said he maintains frequent contact with his son, although the relationship is strained. Overall, the Veteran's description of his social interaction suggests not that he is unable to establish and maintain effective relationships, but only that it is difficult for him. He admits he maintains some relationships with family and friends. He has a few friends, a long-term relationship with his wife, and is in contact with his children. He also engages in some social activities, although he does report avoiding crowds. The Veteran's social functioning overall weighs against a higher rating. The Veteran's thought process was noted to be tangential and over-expansive in his conversations in 2009; and his speech was slow deliberate, and circumstantial at times, though easily redirected in 2011. This would demonstrate impaired thinking, which is one of the criteria for a 70 percent rating; however, impaired abstract thinking is also one of the criteria for a 50 percent rating. Also, the Veteran's speech is more closely described by the 50 percent rating criterion of circumstantial, circumlocutory, or stereotyped speech; rather than the more severe symptoms of speech that is intermittently illogical, obscure, or irrelevant, that is one of the criteria for the 70 percent rating. Thus, overall, the Veteran's impairment in speech and thought process does not more nearly approximate the criteria for a 70 percent rating. With regards to his occupation, the Veteran is not working. According to his August 2005 VA examination, his PTSD symptoms largely unaffected him occupationally until an explosion at work caused him to have a flashback and prompted his retirement after 31 years at the same company. The Veteran also noted that he quit working due to his age/ duration of work. In his November 2010 appeal to the Board, the Veteran pointed to the letter from his VA treating physician in which she recounts his intense combat nightmares and history of suicidal thoughts and described his PTSD as severe. The Veteran argues the letter supports a higher rating. However, the doctor's characterization of the Veteran's PTSD as "severe" is not sufficient by itself to warrant a higher rating. The Board has considered the specific symptoms described by the doctor, including nightmares, flashbacks, hypervigilance, and history of suicidal thoughts, and the severity of those symptoms as reflected by all of the Veteran's medical records. The Veteran's reports at his recent VA examinations and at his appointments with a VA psychologist in October 2010 do suggest the Veteran's symptoms have worsened somewhat since he was first assigned a 50 percent rating for his PTSD. His sleep disturbances involve a physical component of thrashing and injuring himself or property. At his January 2011 evaluation he professed having suicidal thoughts twice a month. However, the Veteran also demonstrates a fair level of functioning. He has always been found to be alert and oriented and adequately groomed with adequate eye contact. The January 2011 examiner further found the Veteran to have fair insight and judgment, appropriate impulse control, and intact memory. The examiner did note the Veteran was circumstantial at times but said he was easily redirected. Overall, even considering any worsening of symptoms, the Board finds the Veteran's condition is still best represented by a 50 percent disability rating. The Veteran's GAF scores also support a 50 percent rating. The November 2009 and January 2011 VA examiners assigned GAF scores of 61 and 55 respectively. A score of 61 indicates mild symptoms, while a score of 55 is assigned for moderate symptoms or difficulty in social, occupational, or school functioning. It is important for the Veteran to understand that without problems associated with his PTSD, there would be no basis for the current 50 percent evaluation. Further, a 50 percent evaluation indicates a considerable disability evaluation that would include many of the problems the Veteran has described. The Board has reviewed the Veteran's statements in detail and finds that the Veteran does not meet the next higher criteria, as he does not have deficiencies in most areas. He has limited social interaction but still maintains relationships with his wife and son, albeit somewhat strained relationships, and he also has friends and participates in a golf league. He also has suicidal ideation, which is a criterion for the 70 percent. But, again, socially he has more moderate impairment, even with the exacerbation of symptoms in October 2010 when it was noted that he was becoming more of a recluse and his appearance was in the decline. Moreover, the isolated and general finding of his appearance being in decline in 2010 and the note in 2011 that he had not shaved does not rise to the level of neglect of personal appearance and hygiene. He was noted to be otherwise adequately groomed in 2011. Occupationally, he is not working and the record suggests this is, in part, due to his PTSD symptoms that were exacerbated by an explosion at work. This would suggest difficulty adapting to stressful circumstances in a work-like setting, which is another one of the criteria for a 70 percent rating. However, the Veteran also retired after 30 plus years and when he reached age 62. Therefore, the record does not clearly attribute the Veteran not working entirely to his PTSD symptoms. While the Veteran's PTSD does affect him and cause moderate impairment socially and occupationally, his PTSD does not result in deficiencies in most areas of his life. The Veteran also does not meet the criteria for a 100 percent rating, as the record does not demonstrate total occupational and social impairment. The Veteran argued in November 2010 on his VA Form 9 that his symptoms of suicidal ideation and the findings of severe PTSD should be enough to warrant the next higher 70 percent rating. He cited to 38 C.F.R. § 4.21 (in applying the rating schedule to a disability, it is not expected that all cases will show all the findings specified) and Johnson v. Derwinski, 7 Vet. App. 95 (1994) (finding that only one of the three criteria for a 100 percent rating for PTSD in the pre-1996 regulations need to be met for entitlement to a 100 percent rating for PTSD to be warranted). It is true that not all of the criteria listed in the 70 percent rating need to be shown in the record for entitlement to this rating to be warranted. As noted, the diagnostic criteria under 38 C.F.R. § 4.130 are just suggestive of the symptoms needed for the appropriate ratings, and are not an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the Board has determined that based on the evidence of record, for the reasons described above, that the symptoms of the Veteran's PTSD, while significant, do not demonstrate deficiencies in most areas of his life. Primarily he is still shown to have, at most, moderate social and occupational impairment. The Board has taken into consideration the Veteran's lay statements regarding the severity of his PTSD. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006)). However, the Veteran is not competent to provide medical determinations with respect to the severity of the PTSD and the Board has relied on the medical evidence of record in this regard. Thus, to the extent that the Veteran has contended that his PTSD is more severely impaired than the rating assigned, the preponderance of the evidence is against the claim; and the benefit of the doubt doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). For all the foregoing reasons, the Board finds that the evidence supports the assignment of a 50 percent rating, but no higher, for PTSD. Therefore, entitlement to an increased rating for the impairment associated with PTSD is not warranted. The Board has considered staged ratings under Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. An inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) also has been considered. The Veteran reportedly retired from employment after reaching the age of 62, and also reported an exacerbation in PTSD symptoms after an explosion at work. While the record shows that the exacerbated PTSD symptoms precipitated the Veteran's retirement, the evidence does not suggest that the Veteran has been rendered unemployable as a result of his PTSD. Therefore, any inferred TDIU claim is inapplicable in this case. The Board has also considered entitlement to an extraschedular evaluation. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2012). In Thun v. Peake, 22 Vet. App. 111, 115 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe a veteran's disability level and symptomatology. If the schedular rating criteria reasonably describe a veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate a veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis in the present case, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria utilized above specifically provide for disability ratings based on a combination of occupational and social impairment, reported symptoms, and clinical findings. The Veteran's PTSD has resulted in such symptoms as nightmares, suicidal thoughts, social difficulties, impaired abstract thinking, circumlocutory speech, mild memory loss, a depressed mood, and increased anxiety and irritability, which is contemplated by his 50 percent disability rating under Diagnostic Code 9411. The Board has also considered and applied the provisions of 38 C.F.R. § 4.20, which provide for rating by analogy based on symptomatology and impairment of a disorder that is not specifically listed, or for symptoms not specifically included in the rating criteria. For these reasons, the Board finds that the schedular rating criteria are adequate to rate the Veteran's service-connected PTSD at issue, and referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b). ORDER Entitlement to an increased rating in excess of 50 percent for PTSD is denied. ____________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs