Citation Nr: 1313360 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 07-37 882 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUE Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from July 1967 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which denied an evaluation in excess of 50 percent for his PTSD. The Veteran timely appealed that decision. The Veteran also initially appealed a claim for a total disability rating based on individual unemployability; a total disability rating based on individual unemployability was awarded, effective April 29, 2008, in a July 2010 rating decision. That matter is not currently before the Board. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's psychiatric symptoms are generally moderate in nature, with occupational and social impairment with reduced reliability and productively due to such symptoms as: flattened affect; disturbances in motivation and mood; difficulty establishing and maintaining effective work relationships; some obsessive/ritualistic behavior, including checking the security of things before being able to sleep; chronic sleep impairment with flashbacks and recurrent nightmares; and evidence of panic attacks. 2. Throughout the appeal period, the psychiatric symptoms are not shown to manifest total or severe occupational and social impairment due to such symptoms as: gross impairment of thought process or communication; persistent hallucinations or delusions; grossly inappropriate behavior; persistent danger to himself or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; severe memory loss such as forgetting his name, or those of his close relatives, or with occupation; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting his ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with episodes of violence; spatial disorientation; neglect of personal appearance and hygiene; and, inability to establish and maintain any relationships. CONCLUSION OF LAW The criteria for an evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) 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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In a claim for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). Here, the Veteran was sent letters in August 2005, March 2006, and June 2008 which provided information as to what evidence was required to substantiate the claim of increased evaluation for PTSD and of the division of responsibilities between VA and a claimant in developing an appeal. The March 2006 and June 2008 letters also explained what type of information and evidence was needed to establish a disability rating and effective date, and the June 2008 letter additionally included the Rating Schedule criteria which would be used to assess the Veteran's PTSD. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims herein decided. The Board acknowledges that this case was initially remanded by the Board in a May 2012 remand. That remand instructed for the Veteran to be afforded a VA examination and for a letter to be sent eliciting information regarding any ongoing psychiatric treatment he may have been receiving. The Veteran underwent a VA PTSD examination in June 2012. He also was sent a May 2012 letter asking him for information regarding any psychiatric treatment he may have received since December 2009; the Veteran has not responded to that letter as of this decision. The Board therefore finds that its remand order has been substantially complied with, and it may proceed to adjudicate upon the merits of this case. See Stegall v. West, 11 Vet. App. 268 (1998) (A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant 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 v. Principi, 16 Vet. App. 183 (2002). Background The Board has reviewed the Veteran's VA treatment records from 2004 through 2012. None of those treatment records reflect any individual treatment of the Veteran's PTSD. The Veteran underwent a 16-week group therapy session from November 2008 through March 2009, though very scant notes regarding any individual symptoms of the Veteran. Those records generally demonstrate that the Veteran attended the sessions and did not voice any suicidal or homicidal ideations, hallucinations or delusions during those sessions. More recent records in 2010 and 2012 demonstrate that the Veteran was asked if he would like to participate in other group therapy sessions, but he has declined due to availability issues. The Veteran has not identified any private treatment that he has received during the applicable appellate period. The Veteran underwent a VA PTSD examination in October 2004. The Veteran reported having problems sleeping, increased guard, and tried to avoid watching coverage of Iraq on television. The Veteran reported that he was able to work and take care of himself, though he was divorced from his wife at her request. He reported having some friends but not as many as he did before service. On examination, the Veteran had no impairment of his thought processes or communication, nor did he have any delusions or hallucinations. He had good eye contact and was interactive throughout the interview. There was no inappropriate behavior, suicidal or homicidal ideations, or memory loss or impairment, either long- or short-term. The Veteran was neat, clean and oriented to person, time and place. He did demonstrate some ritualistic behavior. The examiner noted that he liked to sit in public places where he can watch the door and get out quickly if necessary. His rate and flow of speech were normal, lacking irrelevancies or illogicalities. The Veteran endorsed panic attacks which occur approximately once every two months and leave him feeling totally washed out. The Veteran has depression and sleep problems. The Veteran isolates himself. His wife divorced him 14 years prior to the examination. The Veteran had no impairment of his impulse control. The Veteran was diagnosed with PTSD and assessed a GAF of 55. The Veteran underwent another VA PTSD examination in May 2006. The Veteran did not report any hospitalizations for his mental disorder. The Veteran reported being married and divorced, with 4 children with whom he has good relationships with. He described himself as a loner, however, with only a single girlfriend since his divorce and no other close friends or social life. He occasionally attended church and had no hobbies. The Veteran reported having anxiety, social isolation, anger, sleep problems and loneliness. He did not have any suicide attempts or episodes of violence. On examination, he was clean, neatly groomed and appropriately dressed. He had unremarkable psychomotor activity and speech. He was cooperative and friendly, with a normal affect, though he had an anxious and fearful mood. His attention was intact and he was able to do serial 7's and to spell a word backwards and forwards. He was oriented to person, time and place. He had an unremarkable thought process and thought content. There was no evidence of delusions or hallucinations; he had fair judgment and insight and average intelligence. He had sleep impairment with some daytime sleepiness. He did not have any inappropriate behavior, obsessive/ritualistic behaviors, panic attacks, homicidal or suicidal thoughts, or episodes of violence. He had good impulse control and was able to maintain minimum personal hygiene. There were no problems with his activities of daily living. His remote, recent and intermediate memories were all fair. The Veteran was noted to have social isolation and anger. He was not employed at that time, and he retired due to his diabetes mellitus in 2002. He was diagnosed with chronic PTSD and assessed a 55 GAF. The examiner noted that the Veteran would have a moderate impairment of employment as a result of his PTSD symptoms, including anger, social isolation, anxiety, depression and difficulty concentrating. In a July 2006 addendum, the examiner revised her opinion after reviewing the claims file to indicate that the Veteran would have major functional impairment in his employment as a result of his PTSD symptoms, including depression, anxiety, anger, social isolation, and difficulty concentrating. The Veteran underwent another VA PTSD examination in May 2008; the examiner noted that the claims file was not available for review, though he reviewed the previous VA examination. The Veteran reported increasing frequency of distressing nightmares-occurring approximately every other night and waking him from sleep-and intrusive memories; he also reported having fewer social contacts, particularly since his various moves. He has a depressed mood most days, mild to moderate but occasionally severe. He had episodes of suicidal thoughts about 4 times over the past 12 months; he has not acted on those thoughts and he did not want to act on them, had no intent, or had no plan of self-harm. The Veteran reported decreased energy and more difficulty initiating tasks and following through on things. He is more irritable. The Veteran is more distressed at the sight of Vietnamese people and feels threatened by their presence; such leads to him avoiding them and rarely leaving his home. He avoids movies and conversations about Vietnam and movies with violent themes; he also has frequently-triggered flashbacks when hearing news about Iraq. He mostly works in his garden and stays in touch with a few friends via email. He maintains a close and supportive relationship with his daughter. On examination, the Veteran was casually dressed, though rather disheveled with fair grooming and hygiene. He appeared listless and tired. His mood was mildly anxious and depressed. His affect was congruent and restricted in range. There was no current suicidal ideation. His speech was fluent, and discourse was relevant, concise, and comprehensive. There was no evidence of significant cognitive disturbance. His memory was intact for recent and remote events. Thought process was linear and logical, with content that was free from delusions or obsession; he was noted as having a preoccupation with past traumas, however. The examiner noted that the Veteran was experiencing higher and more frequent levels of his symptomatology, which was impacting his mood and ability to engage in usually-enjoyed activities; the Veteran was described as more withdrawn with episodic passive suicidal ideations. He was diagnosed as having chronic moderate to severe PTSD and was assessed a GAF score of 46. The examiner concluded that the Veteran had moderate disturbance due to his depression, serious disturbance in his personal relationships outside the home, and serious disturbance due to anxiety and core symptoms of his PTSD. The Veteran underwent a VA PTSD examination in December 2009. The examiner noted that he reviewed the claims file. He further noted that the Veteran had last had any PTSD treatment in March 2009 at VA; the Veteran had not been hospitalized for his mental health disorder. The Veteran reported that he currently lived with his girlfriend and adult daughter; he had good relationships with his girlfriend and all of three of his children and grandchildren. He additionally reported long-term friendships with positive relationships, but little contact. The Veteran had no suicide attempts. The Veteran reported some irritability but no anger outburst. He was engaged in constructive hobbies, such as working with stained glass or gardening, though such were solitary activities. The Veteran also appeared to have difficulty in situations outside his family and their homes; social situations, restaurants, etc. were difficult for him to cope with. On examination, the Veteran was clean with unremarkable psychomotor activity and speech; he had a cooperative attitude, a good mood and appropriate affect. The Veteran's attention was intact and he could do serial 7's and was able to spell a word forwards and backwards. He was oriented to person, time and place. His thought process and content were unremarkable, without delusions or hallucinations. He reported having sleep impairment, with nightmares two to three times a week; the nightmares awaken him and he has difficulty returning to sleep afterwards. The Veteran did not have any inappropriate behavior. The Veteran was noted as having obsessive/ritualistic behaviors, which included having to check car, windows and doors before going to bed, and that he is unable to go to bed without having completed this task. The Veteran did not report any panic attacks, homicidal thought, suicidal thoughts, or episodes of violence; he had good impulse control. He was able to maintain minimum personal hygiene and did not have any problem with his activities of daily living. His memory was normal. The examiner noted that the severity of the Veteran's symptoms was moderate. The Veteran specifically reported having: irritability, nightmares, flashbacks, hypervigilance, difficulty concentrating, social isolation and anxiety as a result of his psychiatric disorder. He was diagnosed with PTSD and assessed a GAF of 69. The Veteran was noted as being unemployed, but having retired in 2003. The examiner noted that there was not total occupational and social impairment secondary to his psychiatric disorder, though the Veteran's symptoms did result in deficiencies, including in thinking, family relations, work, and mood. The Veteran was noted as being unable to do some activities like crosswords due to his difficulty concentrating, reported being less angry than in the past though his family knew of his temper and commented on his anger, and he noted that he had trouble interacting with others and concentrating at work when he was employed. The Veteran also reported having irritability and depressed moods at times. The Veteran reported that his flashbacks and nightmares had worsened since his last examination, but that his anger was under more control; he related that he was extremely agitated by information of the wars in Iraq and Afghanistan and felt that the "kids [were being sent] over there for politics just like they did me." Finally the Veteran underwent a VA examination of his PTSD in June 2012. The examiner diagnosed the Veteran with PTSD and assigned a GAF of 60, noting that the Veteran described his supportive marriage as a protective factor. The examiner noted that the Veteran had occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, and symptoms were controlled by medication. The examiner noted that she reviewed the claims file. The Veteran currently resided with his wife of 7 months, noting that he had been divorced once from his ex-wife in the distant past, approximately 25 years ago. The Veteran and his current wife had been together for the past 3 years and he described the relationship and "real good." He and his wife enjoyed travelling, and were both actively involved in their church. The Veteran additionally enjoyed spending time with his 5 grandchildren and 4 children, all of whom he had a good relationship with. The Veteran had a friend he occasionally spent time with, but that most of the time was spent with his wife. The Veteran continued to have general feelings of irritability, but did not have any anger outbursts; though, he related experiencing anxiety and stress when confronted with very specific Vietnamese-related stimuli/cues in his environment. The Veteran related that he retired in 2001 from the Department of Defense, where he worked for 21 years after being credited with 3-4 years of active duty service. He was an education technician and test examiner; he stated that he did not experience any type of work-related problems including relationship or social relationship difficulty with supervisors or coworkers during his career. The Veteran's vision was deemed poor in 2001, as a result of his diabetes, and he was forced to retire; he has not worked since that time. The Veteran noted that he was mostly limited by leg pain and tiredness due to his diabetes as opposed to any psychiatric restrictions on his employability. The Veteran reported that he had private treatment for his psychiatric disorder but quit because it was too expensive prior to seeking treatment with VA for about a year from 2005 to 2006; he stated that he has not had any other VA psychiatric treatment, and the examiner noted that was confirmed in the Veteran's VA medical records. The Veteran reported no legal or substance abuse problems related to his psychiatric condition. On examination, the Veteran was shown to have the following symptoms: depressed mood, chronic sleep impairment, mild memory loss such as forgetting names, directions, or recent events, flattened affect, and suicidal ideations. The Veteran stated that he continued to experience nightmares on a regular basis, with the content of those being his past experiences in Vietnam. The Veteran additionally continued to have triggers involving Vietnamese people or Vietnam movies which led to recollection and disturbing memories. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider a veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Id.; Powell v. West, 13 Vet. App. 31, 35 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran has been awarded a 50 percent evaluation for his psychiatric disorder throughout the appeal period. That disability evaluation was assigned under 38 C.F.R. § 4.130, Diagnostic Code 9411. Diagnostic Code 9411 is governed by a General Rating Formula for Mental Disorders. Under the General Rating Formula, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130 (2012). A 70 percent rating is warranted for 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 work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for 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; 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. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF score of 61 to 70 indicates some mild symptomatology (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, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). 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). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2012). Based on the foregoing evidence, the Board finds that a 50 percent evaluation is appropriate and the Veteran's claim is denied. During the appeal period, the Veteran has demonstrated such symptoms as: flattened affect; disturbances in motivation and mood; difficulty establishing and maintaining effective work relationships; some obsessive/ritualistic behavior, including checking the security of things before being able to sleep; chronic sleep impairment with flashbacks and recurrent nightmares; and panic attacks. The Veteran is not shown to have such symptoms as: gross impairment of thought process or communication; persistent hallucinations or delusions; grossly inappropriate behavior; persistent danger to himself or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; or, severe memory loss such as forgetting his name, or those of his close relatives, or with occupation. The Veteran exhibited suicidal ideations at the May 2008 VA examination. However, these were occasional and he did not have an intent to act upon them. He did not exhibit other criteria for a higher evaluation. The Board finds that the Veteran does not have occupational and social impairment in most areas, such as work, school, family relations, judgment, thinking or mood. The Board notes that the most recent VA examination shows mild to moderate deficiencies in these areas, but not severe impairment. The Veteran's speech is not intermittently illogical, obscure or irrelevant throughout the appeal period, nor does he have any spatial disorientation, neglect of personal appearance or hygiene, or near-continuous panic or depression affecting his ability to function independently, appropriately and effectively. The Veteran has some social isolation and problems relating to people, but that such is not severe in nature. In fact, the Veteran has demonstrated an ability to relate to and interact with his family and new wife very well and effectively throughout the appeal period. Such does not demonstrate an inability to establish or maintain any relationships at all. The Veteran is also shown to have irritability throughout the appeal period, but consistently is described as having no anger outbursts and having good impulse control. Thus, the Veteran does not demonstrate any severe symptomatology in those areas of his functional impairment. While the 2006 VA examiner suggested that PYSD resulted in major functional impairment and GAF scores in 2008 were in the 40s, the symptoms reported during the examinations in 2006 and 2008 were mostly moderate. They did not meet or approximate the criteria for a higher evaluation. The findings were not that much different than those made in examinations prior to 2006 and after 2008 and the clinical evidence does not reflect more than moderate symptomatology. In short, while the Board acknowledges that the Veteran has some symptoms that are demonstrable of a severe functional impairment due to his psychiatric disorder, the Board finds that such symptoms and his overall functional impairment are only moderate in nature throughout the appeal period. Such is supported by the Veteran's fairly consistent GAF scores throughout the appeal period, as well as his numerous VA examinations. Again, the Veteran's symptoms generally include: flattened affect; disturbances in motivation and mood; difficulty establishing and maintaining effective work relationships; some obsessive/ritualistic behavior, including checking the security of things before being able to sleep; chronic sleep impairment with flashbacks and recurrent nightmares; and panic attacks. The Veteran's symptomatology, however, is not productive of a severe or total impairment in his occupational and social functioning, with such symptoms as: gross impairment of thought process or communication; persistent hallucinations or delusions; grossly inappropriate behavior; persistent danger to himself or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; severe memory loss such as forgetting his name, or those of his close relatives, or with occupation; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting his ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with episodes of violence; spatial disorientation; neglect of personal appearance and hygiene; and, inability to establish and maintain any relationships. Accordingly, the Board finds that an evaluation in excess of 50 percent for PTSD must be denied on the evidence of record at this time. See 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation is adequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected PTSD, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorder. As the rating schedule is adequate to evaluate the disability, referral for extraschedular consideration is not in order. ORDER Entitlement to an evaluation in excess of 50 percent for PTSD is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs