Citation Nr: 1315176 Decision Date: 05/08/13 Archive Date: 05/15/13 DOCKET NO. 01-08 878 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial rating in excess of 10 percent for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran had active military service from March 1970 to April 1973. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a March 2000 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This rating decision granted the Veteran's petition for service connection for PTSD and assigned a 10 percent disability evaluation effective from October 24, 1997. The Veteran was notified of that action and he appealed, claiming that the evidence showed that a higher rating should be assigned. In July 2003, the Board remanded the case for further development by the originating agency, including scheduling of an examination. Upon completion of the remand instructions, the case was returned to the Board for further consideration. In November 2005, the Board denied the Veteran's claim of an initial rating higher than 10 percent for PTSD. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In August 2006, the Court vacated the Board's decision and remanded the case for readjudication in compliance with directives specified in an August 2006 Joint Motion filed by counsel for the Veteran and the VA Secretary. In July 2007, the Board denied the Veteran's appeal again. The Veteran appealed this decision to the Court. In January 2010, the Court issued a decision which vacated the Board's July 2007 decision, and remanded the case to the Board for action consistent with its decision. In July 2010, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. The Veteran submitted additional pertinent evidence in August and October 2012, which has not yet been considered by the RO. However, the Veteran submitted a waiver of initial RO consideration of that evidence. Cf. 38 C.F.R. § 20.1304 (2012). FINDING OF FACT Throughout the entire initial rating period on appeal, the Veteran's PTSD has manifested occupational and social impairment due to mild or transient symptoms, including sleep impairment, nightmares, anxiety, and depression. CONCLUSION OF LAW The criteria for a disability rating in excess of 10 percent for PTSD are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The appeal arises from disagreement with the initial rating following the grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The United States Court of Appeals for Veterans Claims (Court) has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as an effective date) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. There has been no allegation or evidence of prejudice. The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103S; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.1599(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records and VA and private treatment records. The Veteran has reported in many letters that there are records of treatment for his psychiatric disability in prison, subsequent to 1998, not currently associated with the claims file. He specifically noted in his July 2012 and August 2012 statements, that the December 2011 VA examiner did not review these records. However, the Veteran was notified in a November 2010 letter that there would be a fee for obtaining copies of these records, and that he was required to obtain the records as VA cannot pay for them. The Veteran indicated in subsequently received correspondence that he could not afford to pay for the records. He noted further that he had reviewed the records dated after February 1998, which showed continuity of his symptoms already reported in records associated with the claims file, and that as his condition had not changed, the additional records dated after February 1998 were redundant. Accordingly, the Board finds that it is clear that additional efforts to obtain such records would be futile. The Board notes that, besides these prison treatment records, all pertinent evidence has been obtained in this case. Neither the Veteran nor his representative has identified any additional evidence that could be obtained to substantiate the claim. Additionally, the Veteran was provided a proper VA examination in December 2011 for his psychiatric disability. The Board notes that the Veteran, in his August 2012 statement, claimed that the December 2011 examination was inadequate because the examiner did not inquire as to his current PTSD symptomatology. However, after reviewing the examination report, the Board finds that the examiner did note current and past symptoms related to the Veteran's psychiatric disability. Furthermore, the examination report contains sufficient information to permit the disability to be accurately rated. As such, the Board finds that the examination was adequate. In addition, there is no evidence or contention that there has been a change in the Veteran's symptoms since the last examination. The Board remanded the claim in July 2010 to confirm the Veteran's representative, and to afford him a VA examination. The Board was notified by Disabled American Veterans in March 2011 that they were representing the Veteran, and the Veteran was afforded a VA examination in December 2011. As noted above, the examination provided sufficient information to permit the disability to be accurately rated, as was requested in the remand. The remand instructions were thereby complied with. Stegall v. West, 11 Vet. App. 268 (1998). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). 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 their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). A 10 percent rating is warranted for PTSD if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is warranted for PTSD if 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, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted for PTSD if it is productive of 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, Diagnostic Code 9411. 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent evaluation 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; 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. 38 C.F.R. § 4.130, Diagnostic Codes 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is based on 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 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). Scores ranging from 31 to 40 reflect "Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school)." Id. A score of 41 to 50 is indicated where 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)." Id. A score of 51-60 is appropriate where there are, "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)." Id. A score of 61-70 is indicated 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 generally functioning pretty well, has some meaningful interpersonal relationships." Id. The symptoms listed in the criteria for a 50 percent evaluation are not intended to serve as an exhaustive list, but as examples of the type of symptomatology that would warrant that evaluation, but without those factors, differentiating a 30 percent evaluation from a 50 percent evaluation would be difficult. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational and social impairment equivalent to that which would be caused by those listed in the rating criteria the appropriate equivalent rating will be assigned. Mauerhan v. Principi, at 442. In accordance with 38 C.F.R. §§ 4.1, 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to this disability. The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to his claims. Analysis The Veteran was granted service connection for PTSD in the March 2000 rating decision on appeal. An evaluation of 10 percent was assigned, effective October 24, 1997. The Veteran contends that the PTSD symptoms that he experiences warrant an initial rating higher than 10 percent. He feels he should be awarded at least a 30 percent rating. In essence, the evidence shows that the Veteran's PTSD has been productive of symptoms that are listed in the 10 percent, 30 percent, 50 percent and 70 percent, levels. The symptoms themselves, however, are not the determinative factor; rather, it is the resulting social and occupational impairment that is paramount. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Veteran has been incarcerated since 1993, during the entire period of this appeal. His initial claim of service connection for PTSD was received in July 1996. The only medical treatment that he has received has been treatment offered by the prison. The VA has obtained those records, as noted above, and they are included in the claims folder. June 1995 and July 1997 reports by a prison psychological specialist indicate that the Veteran showed no signs of significant mental or emotional impairment. A September 1997 report by the same prison psychological specialist indicates that the Veteran did show signs of mild to moderate mental or emotional impairment, which could be managed on an outpatient basis, and that mental health staff would provide the necessary care. The record also contains an August 1995 report of a prison PhD senior psychologist who interviewed the Veteran on his request to attend the Vietnam Veterans group. The psychologist observed that the Veteran was clean and neatly groomed with cooperative behavior. He was oriented times three. There were no apparent deficiencies or limitations of memory observed or reported. His mood was calm and appropriate. He showed a broad range of affect, which was congruent with the content of expressed thought, and stable. No suicidal or homicidal ideation was reported. His thinking was coherent, relevant, logical, well-organized, and goal-directed. No abnormal perceptions were reported. His insight and judgment appeared good. The psychologist noted that the Veteran had a history of depressive disorder, and had possible PTSD or stress-related conditions related to military service. The Veteran was placed on the waiting list for the Vietnam group pending confirmation of his service records. He was advised of the availability of mental health services as needed. The record also contains the only detailed summary of the Veteran in a prison psycho-social assessment by a Master's degreed social worker, psychological specialist, dated in December 1996. The report of that examination was co-signed by a senior psychologist. At that examination, the Veteran denied any mental health treatment prior to his incarceration. He had been attending Vietnam Veterans stress groups for about a year. He was taking medication to help him sleep and for depression. He reported that he could not sleep through the night due to nightmares. He also reported that he tended to minimize his depression. The psychologist's gave an Axis I diagnosis of PTSD and Depressive Disorder based on DSM-IV criteria, and assigned a GAF score of 65-70. The examiner noted specific PTSD symptoms of flashbacks, nightmares, minimization of his problems, and anxiety. The Veteran was admitted to mental health outpatient therapy using the Vietnam Veterans group as the vehicle for that therapy. The record contains monthly summaries of the Veteran's participation in group therapy, and some reports of individual therapy sessions, from September 1995 to January 1998. The remaining treatment records in the file relate primarily to treatment reports for the Veteran's physical health. The September 1995 mental health outpatient treatment report notes that the Veteran was clean and neatly groomed, cooperative, and oriented times three. His affect and mood were calm, appropriate and congruent. Thinking distortions were addressed in treatment, and there was no evidence of a formal thought disorder. No suicidal or homicidal ideation was reported. There was no evidence of abnormal perceptions. This was the Veteran's first group session, and it was noted that he handled instructions well, and was well-accepted by the other members. A May 1996 outpatient treatment report contained similar observations about the Veteran. However, the Veteran's mood was noted to be euthymic with appropriate affect. It was noted that the Veteran continued to open up more verbally to the group, offering his own advice and advice from his own experiences. In fact, all of the mental health reports made similar observations about the Veteran's mental health. In a September 1996 report from an individual therapy session, the Veteran talked of his Vietnam experiences and his PTSD. He thought he was probably suffering from it in Vietnam. It also appeared that his Vietnam experience had had a negative influence on the rest of his life. He used to explain his behavior as over reaction, but looking back he felt it was due to PTSD. He felt that the offense for which he was incarcerated could be a case in point. In an October 1997 report from an individual therapy session, the Veteran reported that he was doing fine. His appearance was noted to be neat and clean. His behavior was appropriate and cooperative. He had good eye contact, and presented as relaxed and spontaneous. He was oriented with good concentration and attention. His mood was euthymic. He denied suicidal or homicidal ideation. His affect was congruent and broad, and moderately cheerful. His thinking process was organized and goal oriented with logical and coherent content. No hallucinations or delusions were observed. The Veteran reported that he was sleeping good, 8 hours a night; his appetite was good; and his energy level was moderate within normal limits. He also reported that he experienced anxiety intermittently, but it was manageable and minimal. The record also contains an updated January 1998 report of a psychosocial evaluation of the Veteran by a prison senior psychologist. He noted that the Veteran received correspondence from his children and regular visits from his family. The Veteran was presently in the open prison population, functioning adequately, with a good adjustment to incarceration. He continued with case management, and was a member of a Vietnam Veterans group at the prison. He was seeking disability from the United States Government for his Vietnam experiences. The psychologist made a similar DSM-IV diagnosis as was given in December 1996, but he did not assign a GAF score. He did note that the Veteran's anxiety was asymptomatic at that time. The January 1998 individual therapy treatment report, the last report in the record, contained similar observations about the Veteran's mental health status as noted above. The Veteran did report that he was still sleeping 8 hours a night, and he denied an anxious or irritable mood at that time. He also reported that he was going to be away for four weeks at another facility for law clerk training, which would begin during February 1998. In connection with his initial July 1996 claim of service connection for PTSD, the Veteran submitted a statement in support of his claim by his sister, who described how he was changed after he returned from Vietnam. According to his sister, he avoided socializing, and often absented himself from family gatherings. He had no interest in sports, kept weapons nearby, and used drugs regularly. She stated that these changes were contrary to every point in his personality before going to Vietnam. In an April 1997 statement, regarding PTSD symptoms that he experienced after service, the Veteran stated that he believes that the crime for which he was convicted (murdering his wife), and for which he is currently incarcerated, was due to an impulsive defense reaction that resulted in violence (the record shows that the incident occurred during 1991). He stated that he has had difficulty with intimate relationships having had two failed marriages. His first wife left him shortly after his return from Vietnam, and his second wife told him that living with him was like living with a ghost. The Veteran also related how he experienced difficulty in work relationships after he returned from Vietnam. He stated that he had had five jobs in two months in prison. Prior to obtaining professional employment around 1981, he reported working at a variety of jobs without stability. During the 10 years between 1981 and 1991, he had four different jobs as a computer programmer/analyst. Although the Veteran reported that he had a tendency to candidly verbalize his opinions, and he made great efforts to avoid confrontations, his job changes were primarily motivated by personality disorders, and they were more frequent than he would have preferred. He stated that he had difficulty concentrating at work, and his work was interrupted several times a week by thoughts and memories of Vietnam. While his family was important to him, he avoided contact with them, which was not the way he was before he went to Vietnam. He never indulged in use of marijuana in the field, but he did begin smoking it in Vietnam. This carried over to civilian life for the calming effect. The Veteran also stated that he rarely slept through the night. He was awakened easily, sometimes with war-related nightmares. He would use marijuana often in the early morning in order to get back to sleep. In a February 2001 notarized statement, the Veteran further described his PTSD symptoms. They included occupational impairment due to impaired concentration and memory, intrusive recollections of Vietnam, difficulty sleeping, combat-related nightmares, and social impairment and isolation (he referred to the April 1997 stressor statement noted above). The Veteran also stated that after he returned from Vietnam, he avoided reminders of the war, including fireworks displays, and was no longer interested in sports. He said that he did not discuss his difficulties with socializing or his nervous reactions with his family, and he made every effort to appear normal despite internal turmoil. He reported that in prison, he identified mostly with other Veterans, but basically kept to himself. The record also contains an October 2001 statement by the Veteran's mother on his behalf. She presents herself as having a Master's degree in education counseling obtained in 1968. She listed professional experience as a school counselor from 1968 to 1970; a teacher of an emotionally disturbed class from 1970 to 1971; and an adjunct community college professor of music and psychology from 1972 to 1974. She lists no experience beyond 1974. She noted that she was uniquely able to make observations about the personality development of her son both before and after military service. She incorporated the Veteran's statements from his February 2001 affidavit, noted above. She stated that, during conversations with and observing her son, she noted several PTSD symptoms which were consistent with those described in DSM-IV (The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders): (1) recurrent distressing recollections and dreams, primarily involving two particular experiences (in addition to many others) in which her son and the other soldiers with him were helpless, or in uncontrollable situations; (2) the disruptive thoughts, impaired concentration, caused a negative impact on his work efficiency, and occasionally caused him to leave work undone; (3) the related dreams caused lack of sleep, which also decreased his work efficiency; (4) awaking from the dreams with a sudden involuntary movement would startle and irritate his wife, and cause the most basic social impairment; (5) triggering events included certain sound, war related conversations, movies, news reports, and open areas, which caused an avoidance reaction in her son; (6) prior to service, her son participated in sports, clubs and was socially active, but after service he was more withdrawn and had a feeling of alienation, and (7) the Veteran pursued physical and mental exertion during the day in order to minimize interrupted sleep, and he also demonstrated hypervigilence with a need to check around. The Veteran's mother, stating that she utilized the DSM-IV criteria for PTSD, said that she concurred with a prison psychologist's diagnosis of PTSD related to military combat. She also agreed with the Global Assessment of Functioning (GAF) score of 65-70 assigned by the prison psychologist, which she believed placed her son's impairment at 30 to 35 percent. The Board notes that the Veteran's mother is not a licensed medical doctor/psychiatrist, nor is she a licensed clinical psychologist. The brief work experience that she listed did not show that she performed psychological evaluations, nor does her statement rise to the caliber of a professional psychological evaluation of her son. While her educational background has no doubt provided some familiarity with the provisions of DSM-IV criteria for various mental disorders, the Board does not consider her to be a qualified medical professional in this regard. The Board notes that the Veteran's mother is competent to provide her observations about what she observed about the Veteran's personality growth and development, and his behaviors, both before and after service. However, the record does not establish that she has the medical training necessary to offer a competent opinion on matters of medical diagnosis, etiology or level of severity of a disability. 38 C.F.R. § 3.159 (a)(2) (2012); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992) (a lay person is not competent to offer opinions that require medical knowledge). In accordance with the Board's July 2010 remand directives, the Veteran was afforded a VA examination in December 2011 or April 2012. The examiner noted that Department of Corrections records showed that the Veteran attended group therapy from 1996 to 1998. Different evaluations noted symptoms of depression and anxiety, and during a January 1998 psychological examination, he was diagnosed with Depressive Disorder and PTSD, and assigned a GAF score of 65-70. He was noted to be sleeping 8 hours per night, with no observed distress, a euthymic mood, and occasional anxiety that was manageable and minimal. He was also noted by a psychiatrist in January 1998 to be well groomed, cooperative, and euthymic, and memory/concentration/comprehension were all within normal limits, with no cognitive deficits. The examiner also noted that since 1998 the Veteran had been considered MH Status #1, which indicates no need for treatment or medication, and any mental health symptoms had not risen to a level that was unmanageable or resulted in impaired functioning in his environment. He also noted that the Veteran had not sought any new mental health services since 1998. The Veteran was administered the MMPI2 and the Morel Emotional Numbing Test (MENT) for PTSD, an individually administered, two-alternative, forced-choice test of biased responding for PTSD. The Veteran's score on the MENT was below the cut-off score used to identify individuals from the normative sample who were deemed to be malingering PTSD symptoms, and the MMPI2 scores were similar to test results performed in 1995. The Veteran was somewhat guarded and defensive on testing, and the examiner noted that his somatic complaints/concerns, difficulty with authority, introversion and alienation difficulties were most likely influenced by his incarceration since 1991. At the time of the examination, the Veteran was noted to have symptoms of anxiety. In this regard, he reported that he occasionally felt jumpy in prison a few times per week, but that he also had extended periods where he did not. He also complained of occasional avoidance behavior and sleep disruption, due to prison guard headcounts and closing of cells. The Veteran also reported that he kept conversations with other inmates brief, and that he had learned to keep personal information to himself, and learned to identify potential trouble and walk away from situations that could lead to conflict. On mental status examination, the Veteran was cleanly dressed, had good eye contact, and was oriented times 3. His mood was euthymic and congruent to topics. He was cooperative and generally open throughout the examination, and there were no memory or cognitive deficits noted. He had good performance on serial 7s and word spelling, and good vocabulary. General knowledge and reasoning questions were completed successfully. The examiner opined that the confinement to death row and the prison environment contributed to the Veteran's symptoms of anxiety and depression, and that his arrest for attempted murder (twice) contributed to his symptoms of depression and PTSD, however, he concluded that he could only speculate on apportioning across different stressors. The examiner also concluded that some of the Veteran's symptoms were currently in remission and that he had not experienced an exacerbation or aggravation of his mental condition. He also concluded that the records, examination and evaluation of the Veteran did not support the claim of increased mental distress or impairment. The Veteran has also submitted a September 2012 report from S.R., Licensed Marriage and Family Therapist (LMFT), Certified Trauma Specialist, PTSD Expert. S.R. indicated that in September 2012, the Veteran wad administered the Trauma Symptom Inventory, the Impact of Event Scale, the Davidson Trauma Scale, and the Mississippi Scale for Combat-Related PTSD, and that the results of the tests indicated that as a result of the traumatic events he experienced while serving in Vietnam and the subsequent homecoming experience, the Veteran is suffering from "chronic and severe PTSD," and in his opinion, he has suffered for "many years" with the condition. However, S.R. failed to indicate in his report what specific symptoms of PTSD the Veteran experiences, which would allow the Board to rate the disability under the applicable rating criteria. Furthermore, he did not indicate specifically how long the Veteran has been suffering from chronic and severe PTSD, as opposed to just noting that it had been "many years." As S.R.'s report does not contain sufficient detail, the Board finds that it is inadequate for evaluation purposes. The Board has reviewed all the lay and medical evidence of record pertaining to the period on appeal, and finds that the criteria for an initial rating for PTSD in excess of 10 percent have not been met. As noted earlier, the Veteran has been reported to have some of the symptoms listed in the examples for a 30, 50 or 70 percent rating. He has not; however been shown to have the level of symptomatology contemplated for a rating in excess of 10 percent. Throughout the rating period on appeal, the Veteran's PTSD has been productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, but no more. Such degree of impairment of symptoms does not more nearly approximate the criteria for the next higher 30 percent rating under DC 9411. Therefore, the Board finds that the criteria for a 30 percent rating have not been demonstrated for any period. In this regard, an August 1995 evaluation by a prison senior psychologist was essentially normal, except for a notation of the Veteran's history of depressive disorder. Subsequent psychological evaluations and reports dated later in 1995 and 1996 were also normal. During a December 1996 psych-social assessment by a prison examiner, the Veteran reported PTSD symptoms of flashbacks, nightmares, and anxiety. He also reported that he was taking medication to help him sleep and for depression. However, subsequent evaluations in 1997 and 1998 show that the Veteran's sleep impairment and anxiety had abated. All accounts of his mental health status were good, with notations of no more than mild to moderate mental or emotional impairment, and he was even described on more than one occasion, as euthymic and cheerful. The records also show that he acclimated quickly to, was accepted by, and participated regularly with, the other members of the Vietnam Veteran's mental health outpatient therapy group he attended. Furthermore, he was cooperative and allowed within the prison population. He also kept in contact with his family by correspondence and visits by them. In addition, in January 1998, he reported that he was being allowed to go to a different prison for law clerk training. On the other hand, the evidence does not show suspiciousness, nor does it demonstrate the occurrence of panic attacks. In this regard, in her October 2001 statement, the Veteran's mother reported that after his return from Vietnam, the Veteran demonstrated hypervigilance and the need to check around himself. However, the Veteran did not report symptoms of suspiciousness or panic attacks at any time during the initial rating period, including during evaluations with prison psychologists, during his PTSD group therapy in prison, or during his VA examination in December 2011. Furthermore, the evidence does not show chronic sleep impairment. In this regard, although the Veteran reported sleep impairment and nightmares on evaluation in December 1996 and in his April 1997, February 2001 and August 2012 statements, and his mother reported in her aforementioned October 2001 statement that the Veteran experienced sleep disruption due to distressing recollections and nightmares; the preponderance of the evidence, including prison evaluations and therapy notes, group therapy notes, and the recent December 2011 VA examination report, shows that he generally reported sleeping 8 hours a night, with no more than occasional sleep disruption. In addition, the evidence does not demonstrate memory loss. The Veteran reported impaired concentration and memory in his February 2001 statement, however; he never reported such symptoms during prison evaluations or on VA examination, and there was never any objective evidence of memory loss demonstrated during any such evaluation or examination. Furthermore, the evidence does not demonstrate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran reported in his April 1997 and February 2001 statements that after his return from Vietnam, he had difficulty with intimate relationships, avoiding contact with his family, and that he experienced difficulty in work relationships and occupational impairment, prior to and during prison. The Veteran's mother also reported that the Veteran had disruptive thoughts and impaired concentration, which had a negative impact on his work efficiency. In addition, the Veteran's sister reported in her July 1996 statement that the Veteran avoided socializing and distanced himself from family. However, there is no documentary evidence of record to support the Veteran's or his mother's claims of occupational impairment and difficulties at work prior to prison, and furthermore, none of the medical evidence obtained shows that the Veteran was unable to work or have social contact while he has been in prison. The Board also notes that the reports of social isolation and problems with relationships were not reported during prison therapy sessions and evaluations or during VA examination in 2011. Furthermore, despite his incarceration, the evidence shows that he does have regular contact with his family. He also actively participated in the Vietnam Veterans mental health outpatient therapy group, as well as in individual therapy sessions. He also was allowed to go to a different prison for law clerk training. Moreover, there is nothing in the claims folder insinuating that the Veteran has been kept in isolation because he is unable to "get along" with others. Additionally, the medical records do not show that the Veteran has been placed on a suicide watch, and he has not complained of hallucinations or suicidal ideations. The Veteran has also reported impaired impulse control, noting that he believes that the crime for which he was convicted (murdering his wife), and for which he is currently incarcerated, was due to an impulsive defense reaction that resulted in violence. He has also reported that his behavior has at times been an overreaction, which he now believes was a symptom of his PTSD. However, the Board notes that the evidence does not show that the Veteran has a history of unprovoked irritability or verbally or physically violent behavior, and he has not been shown on objective examination to endorse symptoms of poor impulse control. The Veteran, his mother and his sister, have also reported that the Veteran experiences loss of interest in activities, avoidance behavior (avoiding war movies, etc.), and social isolation. However, these symptoms were not consistently reported during psychological evaluations during the appeal period. The Board also notes that the GAF scores of 65-70 assigned during the initial evaluation period are indicative of only mild impairment and are consistent with the assigned evaluation of 10 percent. The Veteran is competent to report the symptoms of his PTSD. His complaints are credible. The Veteran's complaints have been considered in the above noted evidence; however, evaluations for VA purposes have not shown the severity required for a higher schedular rating, as discussed above. To the extent that the Veteran argues or suggests that the clinical data supports an increased disability rating or that the rating criteria should not be employed, he is not competent to make such an assertion. 38 C.F.R. § 3.159 (a)(2) (2012); Espiritu v. Derwinski, 2 Vet. App. at 494. VA must only consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. See Massey v. Brown, 7 Vet. App. at 208. For the reasons discussed above, the Board has concluded that throughout the initial evaluation period, the social and occupational impairment from the Veteran's PTSD has more nearly approximated mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress contemplated by a 10 percent rating than the greater impairment required for a higher rating. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable to this claim. Extra-schedular consideration Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, 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) (2012). 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 the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant'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"). The Veteran's PTSD is manifested by impairment contemplated by the schedular rating criteria. Hence, referral for consideration of an extraschedular rating is not warranted. Total Rating for Compensation Based on Individual Unemployability (TDIU) The Court has held that TDIU is an element of all claims for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU is granted where a Veteran's service connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2011). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2001) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). As discussed above, the evidence does not show that the Veteran's service-connected PTSD, or any other service-connected disability, precludes gainful employment. Accordingly, the Board finds that further consideration of entitlement to TDIU is not required. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). In this regard, the Veteran is presently incarcerated for life, which means that he cannot seek ordinary civilian employment. There is no documentary evidence of his employment history prior to his incarceration. However, as noted above, none of the medical evidence obtained shows that he was unable to work while he has been in prison. On the contrary, the evidence shows that he reported that he was allowed to go to a different prison for law clerk training. Accordingly, the Board finds that further consideration of entitlement to TDIU is not required. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). ORDER An initial rating in excess of 10 percent for PTSD is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs