Citation Nr: 1313857 Decision Date: 04/25/13 Archive Date: 05/03/13 DOCKET NO. 10-00 868 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) from July 19, 2007, to August 31, 2008. 2. Entitlement to an initial evaluation in excess of 30 percent for PTSD since September 1, 2008. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and her father ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from April 2000 to July 2007. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which granted service connection for the PTSD. The RO assigned an initial disability rating of 10 percent, effective July 19, 2007, the day following the Veteran's discharge from the military. The Veteran then perfected a timely appeal of the initial disability rating assigned. A subsequent October 2008 rating decision from the RO in Jackson, Mississippi, continued the 10 percent rating in effect for the PTSD. The RO in Jackson, Mississippi, now has jurisdiction over the appeal. In September 2011, the Veteran testified at a Board hearing held at the local RO (Travel Board hearing) before the undersigned Veterans Law Judge (VLJ). A transcript of this hearing was prepared and associated with the claims file. In February 2012, the Board remanded this appeal to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. Upon remand, the AMC issued another rating decision in October 2012, which increased the disability ratings for the PTSD to 30 percent, effective February 27, 2012, the date of a VA examination that reflected findings sufficient to establish entitlement to a higher evaluation. The Veteran continued to appeal, requesting higher ratings. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (indicating that a Veteran is presumed to be seeking the highest possible rating unless he or she expressly indicates otherwise). In January 2013, the AMC issued another rating decision, which increased the disability rating for the service-connected PTSD to 50 percent disabling from July 19, 2007, to August 31, 2008, and then assigned a 30 percent rating from September 1, 2008. The Veteran continued to appeal, requesting even higher ratings. See AB, 6 Vet. App. at 38-39. The Veteran's Virtual VA paperless claims file was also reviewed in preparing this decision. FINDING OF FACT Since her military discharge, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. From July 19, 2007, to August 31, 2008, the criteria for an initial rating in excess of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.321, 3.326(a), 4.1, 4.7, 4.129, 4.130, Diagnostic Code (DC) 9411 (2012). 2. Since September 1, 2008, the criteria for an initial rating of 50 percent for PTSD are met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.321, 3.326(a), 4.1, 4.7, 4.129, 4.130, DC 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. VA's Duties to Notify and Assist Under applicable law, 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). 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. This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO sent the Veteran an initial duty-to-assist letter in May 2007, while the Veteran was still on active duty. This letter addressed the Veteran's underlying claim of service connection. The increased rating claim flows downstream from a March 2008 rating decision, which initially established service connection for PTSD. The United States Court of Appeals for Veterans Claims (Court) held, in Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91(2006), that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Thus, because the notice provided before service connection was granted was legally sufficient, VA's duty to notify in this case is satisfied. See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). VA also has a duty to assist a Veteran in the development of the claim. This duty includes assisting a Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the appeal has been obtained. The Veteran's STRs and post-service treatment records have been obtained. The claims file does not present evidence that the Veteran is currently receiving disability benefits from the Social Security Administration (SSA) for the disability currently on appeal. Therefore, the Board does not need to make an attempt to obtain these records. She has been afforded VA examinations, and the reports of those evaluations contain all findings needed to properly evaluate her disability. 38 C.F.R. § 4.2 (2012). The Board does not have notice of any additional relevant evidence that is available but has not been obtained. Furthermore, the Veteran was afforded a Board hearing in September 2011. A Board member has two duties at a hearing: (1) a duty to fully explain the issues still outstanding that are relevant and material to substantiating the claim, and (2) a duty to suggest that a claimant submit evidence on an issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See 38 C.F.R. § 3.103(c)(2) (2012); Procopio v. Shinseki, No. 11-1253, 2012 WL 4882287 at 3 (Vet. App. Oct. 16, 2012) (citing Bryant v. Shinseki, 23 Vet. App. 488, 492, 496 (2010)). Here, during the Board hearing, the VLJ specifically noted the issue as entitlement to an increased rating for PTSD, currently ten percent disabling (at that time). The Veteran was assisted at the hearing by an accredited representative from Disabled American Veterans. The VLJ noted the element of the claim that was lacking to substantiate the claim for benefits (i.e., that the symptoms associated with the service-connected disability were more severe than currently rated). The representative and the VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of this claim. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the Veteran nor her representative has asserted that VA failed to comply with the hearing requirements, nor identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the element necessary to substantiate the claim, and the Veteran, through her testimony, demonstrated that she had actual knowledge of the element necessary to substantiate her claim for benefits. As such, the Board finds that the VLJ complied with the aforementioned hearing duties, and that any error in notice provided during the Veteran's hearing constitutes harmless error. The Board is also satisfied as to substantial compliance with its February 2012 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). This included obtaining the Veteran's recent VA treatment records, which were obtained and associated with her Virtual VA paperless claims file. This also included obtaining a VA examination to assess the current severity of the Veteran's PTSD. This examination was conducted in February 2012. Finally, the remand included readjudicating the Veteran's appeal, which was accomplished in the October 2012 Supplemental Statement of the Case (SSOC). Thus, the Board finds that there has been substantial compliance with its remand directives. Id. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's appeal. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Analysis A. General Regulations and Statutes The Veteran's service-connected PTSD has been assigned a 50 percent disability rating from July 19, 2007, to August 31, 2008, and a 30 percent rating since September 1, 2008. 38 C.F.R. § 4.130, DC 9411. The Veteran asserts that she is entitled to higher disability ratings. Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity in civil occupations. Separate DCs identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. Where a Veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson, 12 Vet. App. at 126. If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. Initially, the Board notes that the Veteran was discharged from the military for a temporary disability of PTSD. In this regard, when a mental disorder that develops in service as a result of a highly stressful event is severe enough to bring about the Veteran's release from the active military service, then the rating agency shall assign an evaluation of not less than 50 percent and schedule an examination within the six month period following the Veteran's discharge to determine whether a change in evaluation is warranted. 38 U.S.C.A. § 4.129. Here, the Veteran has been assigned a 50 percent disability rating for her PTSD since July 19, 2007, the day following her discharge. The Board notes that the Veteran was not scheduled for an examination within six months of her discharge from the military. However, the Veteran was afforded VA examinations in July 2008, November 2009, and February 2012 to assess the current severity of the Veteran's PTSD; thus, the Board finds no prejudice to the Veteran in this matter. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2012) (harmless error). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating 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. 38 C.F.R. § 4.126(a) (2012). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The schedular criteria for rating psychiatric disabilities incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130 (2012). PTSD is rated under 38 C.F.R. § 4.130, DC 9411, according to the General Rating Formula for Mental Disorders. Under this general rating formula, a 30 percent disability rating is warranted when there is occupational 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; and, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent disability rating is warranted when 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and, difficulty in establishing and maintaining effective work and social relationships. Id. Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and, inability to establish and maintain effective relationships, warrants a 70 percent disability rating. Id. 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, warrants a 100 percent disability rating. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DSM-IV at 32). Throughout her appeal, the Veteran's GAF scores have ranged from 60 to 70. According to the DSM- IV, which VA has adopted, under 38 C.F.R. §§ 4.125 and 4.130, a GAF score of 51 to 60 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 61 to 70 indicates 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, and has some meaningful interpersonal relationships. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). B. 50 Percent Rating Prior to September 1, 2008 The Veteran asserts that she is entitled to a disability rating in excess of 50 percent from July 19, 2007, to August 31, 2008, for her PTSD. 38 C.F.R. § 4.130, DC 9411. In applying the facts of this case to the above regulations, the Board finds that there is no evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, to warrant a higher initial disability rating. Id. Specifically, treatment records from the Keesler Air Force Base Medical Center dated from September 2007 to May 2008 demonstrate outpatient treatment for PTSD. The Veteran reported the following symptoms: nervousness; sleep problems; intrusive thoughts two to three times per week; flashbacks; irritability; tension; distractibility; decreased energy; anxiety; decreased concentration; memory loss; and, nightmares. Following a physical examination of the Veteran, the clinical social worker found that the Veteran was appropriately dressed and groomed. She did not demonstrate any abnormalities in her behavior or attitude. Her mood was euthymic and her affect was normal. Her speech was normal. The social workers and physicians found that the Veteran was not a suicide or homicide risk, and that she did not have any impairment in her cognitive functioning or thought processes. At an October 2007 treatment visit, in particular, the Veteran reported that her children were thriving, and she described a trip that she and the children took recently to Walt Disney World. At the October 2007 visit, the Veteran also described her recent church activity. At a February 2008 outpatient treatment visit, in particular, the Veteran told the physician that she loves her new job, but that the job does cause her "high anxiety." Following her July 2007 military discharge, the Veteran was afforded a VA examination in July 2008 to determine the current severity of her service-connected PTSD. The Veteran told the examiner that she was currently employed and enjoyed her job. She denied any significant problems or absenteeism at her employment. The Veteran was currently divorced with three children. The Veteran described the following symptoms: some memory loss; anxiety; distractability; nightmares; flashbacks; irritability; anger; frustration; diminished energy; fatigability; and, avoidance of TV programs, fireworks, crowds, and some military friends. The Veteran stated that she was social with involvement in her church and many friends. However, the Veteran did not like to leave her home. The Veteran reported talking to another person over the Internet, but was not in an intimate relationship. Following a physical examination of the Veteran and a review of the claims file, the July 2007 VA examiner found that the Veteran was oriented to person, place, time, and situation. The Veteran's speech functions were within normal limits as to rate, rhythm, volume, prosody, and fluency with no evidence of paraphasic errors noted. She maintained her activities of daily living independently. Her thought processes were logical and linear. Her thought content was within normal limits. There was no evidence of a perceptual disorder or concentration problems. No abnormalities in the Veteran's behavior were noted. The Veteran's insight was adequate, and her judgment was functional. There were no significant impairments in the Veteran's communication or thought processes. The Veteran denied any suicidal or homicidal ideation. Overall, the VA psychologist found the Veteran's PTSD to be mild and assigned a GAF score of 70. After careful consideration of all evidence, the Board finds that the evidence does not warrant an initial disability rating in excess of 50 percent for the Veteran's PTSD, from July 19, 2007, to August 31, 2008. 38 C.F.R. § 4.130, DC 9411. In this regard, occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, is not demonstrated by the evidence of record. Id. The competent evidence shows that the Veteran's service-connected major depressive disorder has been mildly to moderately disabling throughout the appeal period, which warrants a 50 percent rating. Id. Regarding occupational impairment, throughout this entire appeal period, the Veteran has been employed. The Veteran reported anxiety at her job, but this level of anxiety did not prevent her from being employed. At a February 2008 outpatient treatment visit, the Veteran even told the physician that she loved her new job. At her July 2008 VA examination, she denied any significant problems or absenteeism at her employment. Regarding social impairment, throughout this entire appeal period, the Veteran had relationships with her children, and even traveled with them. The Veteran also participated in activities at her church. At the July 2008 VA examination, the Veteran reported having many friends. Regarding deficiencies in the areas of work and school, the Veteran was currently employed full-time and was not in school. The Veteran did not have a deficiency in the area of family relations as she had meaningful relationships with her three children. Impairments in the Veteran's judgment, thinking, and mood were also not shown at the July 2007 VA examination. The treatment records contained in the claims file do not provide contrary evidence to that obtained at the VA examination, and instead support the examination results. Furthermore, the 50 percent disability rating is supported by the Veteran's GAF scores, which have ranged from 60 to 70 during the course of this appeal period, indicating mild to moderate psychiatric symptoms. See DSM-IV at 44-47. Additionally, with the exception of difficulty in adapting to stressful circumstances, the Veteran did not display any of the enumerated symptoms for the 70 percent disability rating. 38 C.F.R. § 4.130, DC 9411. In contrast, the Veteran displays the majority of the enumerated symptoms for the 50 percent disability rating. Id. The competent evidence shows that the Veteran's service-connected major depressive disorder has been mildly to moderately disabling throughout the appeal period, which warrants a 50 percent rating. Id. The Veteran's symptoms also do not appear to have changed significantly during this initial rating period so as to warrant a staged rating. Fenderson, 12 Vet. App. at 126. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what she observes or experiences. For example, she is competent to report that she experiences certain symptoms, such as anxiety, and she is credible in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's competent and credible belief that her disability is worse than the assigned rating, however, is outweighed by the competent and credible medical examination that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiner has the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. In sum, the preponderance of the evidence is against the assignment of an initial disability rating in excess of 50 percent for the service-connected PTSD, from July 19, 2007, to August 31, 2008. Thus, the appeal is denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see Gilbert, 1 Vet. App. at 53. C. 30 Percent Rating Since September 1, 2008 The Veteran asserts that she is entitled to a disability rating in excess of 30 percent since September 1, 2008, for her PTSD. 38 C.F.R. § 4.130, DC 9411. In applying the facts of this case to the above regulations, the Board finds that there is evidence of occupational and social impairment with reduced reliability and productivity, to warrant a higher initial disability rating of 50 percent since September 1, 2008. Id. Specifically, in October 2008, the Veteran was treated by the Keesler Air Force Base Medical Center for her PTSD. The Veteran experienced flashbacks three to four times per week, and insomnia with nightmares and panic attacks three times per week. The Veteran reported hypervigilance and emotional numbing. The Veteran stated that she had not felt happy since she deployed in 2003, but then she denied a consistently depressed mood. The Veteran described worsening anxiety, sleep, concentration, recall, hypervigilance, and social isolation. The Veteran was employed full-time, but had to leave work early approximately once per week due to anxiety attacks. The Veteran lived with her three children, and had support from the local church. The Veteran denied any psychiatric hospitalizations, hallucinations, delusions, suicidal ideation, or homicidal ideation. Following a physical examination of the Veteran, the psychiatrist found the Veteran's speech to be normal and her mood to be anxious. Her affect was of limited range and mild-to-moderate intensity. She was alert and oriented. Her insight was fair and her judgment was good. Her thought processes were logical, coherent, and goal-directed. The psychiatrist assigned a GAF score of 60 based on the Veteran's chronic flashbacks, nightmares, hypervigilance, insomnia, and emotional numbing. The psychiatrist found that the Veteran's chronic PTSD had a definite social industrial impairment, and that the Veteran's anxiety "likely contributed" to her longstanding social isolation. The Veteran was afforded a VA examination in November 2009 to assess the current severity of her PTSD. The Veteran told the VA examiner that she was currently employed full-time. She reported missing some days from work because she felt tired and fatigued. She described flashbacks approximately four times per week, emotional numbness, fatigue, nightmares, some anxiety and depression, and exaggerated startle response buildup. The Veteran lived with and supported her three children. The Veteran reported that she slept on her living room floor, so that she could be vigilant and watch the door. The Veteran denied any homicidal or suicidal ideations. The Veteran indicated that her mood was sometimes blunted and sometimes anxious and sad. The Veteran stated that she continued to avoid crowds and watching things on television that would remind her of her military experiences. She denied any significant problems maintaining her activities of daily living. The Veteran reported memory problems, but upon an examination, the VA examiner found that the Veteran's memory was adequate and "grossly intact." The examiner noted that the Veteran's prescribed Opana medication, a type of morphine, could be causing her complaints of memory problems, seeing things that she knew were not there, and emotional blunting. The Veteran also complained of concentration problems, but the examiner found that these problems were not demonstrated at the examination. Following a physical examination of the Veteran, the November 2009 VA examiner found that the Veteran's speech was normal and appropriate. Her affect showed good range in the interview and was appropriate in content and context. Her judgment was intact. She was dressed appropriately, and oriented to person, place, and time. The examiner found that the Veteran displayed minimal signs of PTSD with "very mild" intrusive thoughts and defensive/avoidance. The examiner noted that the Veteran reported somewhat limited social functioning; however, the examiner pointed out that the Veteran was raising three children independently without significant difficulties. The examiner also noted that the Veteran missed days from work due to her PTSD, but she also descrbied working late other days so she would not get a decrease in her pay. The examiner noted that the Veteran was also attending school full-time while working full-time. In summary, the examiner assigned the Veteran a GAF score of 70, as the examiner found that the Veteran complained of mild symptoms on a daily basis. The examiner found that there did not appear to be any significant increase in the Veteran's symptoms since her last VA examination. The Veteran testified at her September 2011 Board hearing that she believed a combination of difficulties with the VA examiner and her own underreporting of symptoms led to an underestimation of the severity of her PTSD symptoms since her separation from service in July 2007. Accordingly, the Veteran was afforded another VA psychiatric examination in February 2012. The Veteran reported that she was previously married and divorced. She remarried in May 2011, and currently resided with her husband and three children. She worked full-time. The February 2012 VA physician found that the Veteran's PTSD was manifested by the following symptoms: depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss, difficulty in understanding complex commands, and disturbances of motivation and mood. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the Veteran's PTSD was manifested by 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. The examiner found that the Veteran's PTSD symptoms (to include recurrent distressing memories of trauma, recurrent dreams of trauma, hallucinations of combat explosions, feelings of detachment from others, exaggerated startle response, and intermittent poor concentration) caused frequent impairment of occupational and social functioning, to the extent that the Veteran must frequently take anti-anxiety medication to function at a significantly impaired level in her job with disabled Veterans. The examiner found that these symptoms would also markedly impair her functioning in other occupations as well. The examiner assigned the Veteran a GAF score of 65. In a November 2012 statement, the Veteran's private board-certified advance practice registered nurse (APRN-BC), R.B., submitted a medical opinion. R.B. stated that the Veteran has been under his care since 2004, while the Veteran was on active duty, for her PTSD. Since June 2011, R.B. found that the Veteran had displayed periods of minimal symptomology countered with significant exacerbations of her illness. R.B. determined that these exacerbations cause the Veteran significant occupational and social dysfunction when they occur. During periods of increased stress, R.B. found that the Veteran experienced a relapse of her symptoms, to include nightmares, flashbacks, depressed moods, panic attacks, decreased concentration, and intense anger and irritability. At her last appointment, the Veteran told R.B. that she continued to experience frequent intrusive thoughts and illogical fears. The Veteran reported using her relaxation techniques, but stated that sometimes her symptoms are so severe that she has to leave work and take medications to calm down. The Veteran stated that she was currently married, but that sometimes she had to sleep on the floor of her living room at night due to hypervigilance, which caused significant problems in her marriage. In summary, R.B. found that the Veteran had a good prognosis with the exception of "brief, but significant episodes of symptoms relapse during times of increased stress." R.B. did not assign the Veteran a GAF score. The treatment records contained in the claims file do not provide contrary evidence to that obtained at the VA examinations, and instead support the examination results. After careful consideration of all evidence, the Board finds that the evidence warrants an initial disability rating of 50 percent for the Veteran's PTSD, since September 1, 2008. 38 C.F.R. § 4.130, DC 9411. In this regard, occupational and social impairment with reduced reliability and productivity is demonstrated by the evidence of record. Id. Regarding occupational impairment, although the Veteran has been employed full-time since September 1, 2008, the evidence of record demonstrates that the Veteran requires high levels of anxiety medications in order to continue her employment. She often has to miss work or leave early due to her anxiety. The February 2012 VA examiner found that the Veteran's PTSD symptoms cause frequent impairment of her occupational functioning, to the extent that the Veteran must frequently take anti-anxiety medication to function at a significantly impaired level in her job with disabled Veterans. The examiner found that these symptoms would also markedly impair her functioning in other occupations as well. In November 2012, R.B., APRN-BC, found that the Veteran's PTSD exacerbations cause her significant occupational dysfunction when they occur. Regarding social impairment, despite the Veteran's involvement in her church and in her children's lives, the Veteran reported social isolation since September 1, 2008. The October 2008 psychiatrist found that the Veteran's PTSD had a definite social industrial impairment, and that her anxiety "likely contributed" to her longstanding social isolation. At the November 2009 VA examination, the Veteran reported avoiding crowds. The February 2012 VA examiner found that the Veteran's PTSD symptoms cause frequent impairment of her social functioning. In November 2012, R.B., APRN-BC, also found that the Veteran's PTSD exacerbations cause her significant social dysfunction when they occur. Further, since September 1, 2008, the Veteran has displayed the majority of the enumerated symptoms for the 50 percent disability rating, to include: reduced reliability and productivity; panic attacks more than once a week; difficulty in understanding complex commands; impairment of memory; disturbances of motivation and mood; and, difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. In sum, the overall disability picture more nearly approximates the criteria for the assignment of a 50 percent rating since September 1, 2008. 38 C.F.R. § 4.130, DC 9411. However, after careful consideration of all evidence, the Board finds that the evidence does not warrant an initial disability rating in excess of 50 percent for the Veteran's PTSD, since September 1, 2008. 38 C.F.R. § 4.130, DC 9411. In this regard, occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, is not demonstrated by the evidence of record. Id. The competent evidence shows that the Veteran's service-connected major depressive disorder has been mildly to moderately disabling throughout the entire appeal period. Id. Regarding occupational impairment, throughout this entire appeal period, the Veteran has been employed. The Veteran reported anxiety at her job, but this level of anxiety did not prevent her from being employed. None of the physicians who examined the Veteran found that she was unable to work due to her PTSD symptoms. The Veteran is also currently attending school full-time, and she has not indicated at any point since September 1, 2008, that her PTSD interferes with her school activities. Regarding social impairment, throughout this entire appeal period, the Veteran has relationships with her children, and in May 2011, remarried. Although the Veteran reported some marriage difficulties, particularly when she slept on the living room floor during her brief relapse periods, the Veteran was currently married at her private treatment visit in November 2012. The Veteran also participates in activities at her church. Additionally, at the November 2009 VA examination, the Veteran described her social functioning as "somewhat limited," but she stated that she was also able to raise and support three children independently without significant difficulties. Regarding deficiencies in the areas of work and school, the Veteran is currently employed full-time and is in school full-time. The Veteran does not have a deficiency in the area of family relations as she has meaningful relationships with her three children and is currently married. Impairments in the Veteran's judgment and thinking are also not shown at the VA examinations or treatment records dated since September 1, 2008. Further, the February 2012 VA examiner found that the Veteran's PTSD is manifested by 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 - which is not equivalent to occupational and social impairment with deficiencies in most areas, the requirement for the 70 percent disability rating. 38 C.F.R. § 4.130, DC 9411. The treatment records contained in the claims file do not provide contrary evidence to that obtained at the VA examinations, and instead support the examination results. Furthermore, the 50 percent disability rating is supported by the Veteran's GAF scores, which have ranged from 60 to 70 during the course of her appeal, indicating mild to moderate psychiatric symptoms. See DSM-IV at 44-47. Additionally, with the exception of difficulty in adapting to stressful circumstances, the Veteran did not display any of the enumerated symptoms for the 70 percent disability rating. 38 C.F.R. § 4.130, DC 9411. In contrast, the Veteran displays the majority of the enumerated symptoms for the 50 percent disability rating. Id. The competent evidence shows that the Veteran's service-connected major depressive disorder has been mildly to moderately disabling throughout the appeal period, which warrants a 50 percent rating. Id. The Veteran's symptoms also do not appear to have changed significantly during this initial rating period so as to warrant a staged rating. Fenderson, 12 Vet. App. at 126. The Board notes that in adjudicating a claim the competence and credibility of the Veteran must be considered. See Buchanan, 451 F.3d at 1331; Washington, 19 Vet. App. at 368-69. The Board acknowledges that the Veteran is competent to give evidence about what she observes or experiences. For example, she is competent to report that she experiences certain symptoms, such as anxiety, and she is credible in this regard. See, e.g., Layno, 6 Vet. App. at 465. The Veteran's competent and credible belief that her disability is worse than the assigned rating, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. In sum, the Veteran is assigned an initial disability rating of 50 percent for her PTSD, since September 1, 2008. However, the preponderance of the evidence is against the assignment of an initial disability rating in excess of 50 percent for the service-connected PTSD since September 1, 2008. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see Gilbert, 1 Vet. App. at 53. D. Extraschedular Evaluation The above determinations are based on application of provisions of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). However, the regulations also provide for exceptional cases involving compensation. Pursuant to § 3.321(b)(1), the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the claimant's disability level and symptomatology, then a Veteran's disability picture is contemplated by the rating schedule. The assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). Here, because the schedular disability rating of 50 percent for the Veteran's PTSD fully address her symptoms, which include mainly panic attacks, anxiety, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, referral to the VA Under Secretary for Benefits or the Director of Compensation and Pension Service for consideration of an extraschedular evaluation is not warranted. The evidence of record does not establish, and the Veteran does not contend, that her PTSD prevents her from being employed or attending school, or that her PTSD has required frequent hospitalizations. Specifically, in a November 2012 statement, the Veteran reported that she was currently employed, but that her PTSD caused her to miss some days from work. This level of occupational impairment in contemplated in the schedular criteria for PTSD. Additionally, at her recent VA examination in February 2012, the Veteran denied any hospitalizations for her PTSD. Thus, there is no evidence that the Veteran's service-connected disability causes impairment that is not contemplated by the schedular rating criteria or that renders impractical the application of the regular schedular standards. See Thun, 22 Vet. App. at 111. Accordingly, referral of this case for consideration of an extraschedular rating is not warranted. Id.; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996). E. TDIU Consideration Finally, pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a total disability rating based in individual unemployability due to service-connected disabilities (TDIU). TDIU is considered part and parcel of an increased rating claim when the issue of unemployability is raised by the record. In this case, the issue of unemployability is not raised by the record. In a November 2012 statement, the Veteran reported that she was currently employed, and there is no allegation that her service-connected PTSD has resulted in unemployment. Therefore, consideration of a TDIU is not warranted. ORDER From July 19, 2007, to August 31, 2008, an initial disability rating in excess of 50 percent for PTSD is denied. Since September 1, 2008, an initial disability rating of 50 percent for PTSD is granted, subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs