Citation Nr: 1316704 Decision Date: 05/22/13 Archive Date: 05/31/13 DOCKET NO. 09-38 746 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an initial evaluation higher than 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from May 1967 to March 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from a rating decision in December 2006 of a Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. During the pendency of the appeal, in a rating decision in August 2008, the RO increased the rating for PTSD from 30 percent to 50 percent, effective the date the Veteran filed his claim with VA. The Veteran continued his appeal for a higher rating. AB v. Brown, 6 Vet. App. 35, 38 (1993). FINDINGS OF FACT PTSD has been manifested by a disability picture that equates to occupational and social impairment with reduced reliability and productivity; occupational and social impairment with deficiencies in most areas, such as work and family relations, judgment, thinking, or mood has not been demonstrated. CONCLUSION OF LAW The criteria for an initial evaluation higher than 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting Veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre- adjudication VCAA notice by letter, dated in May 2006. The notice included the type of evidence needed to substantiate the underlying claims of service connection, namely, evidence of an injury or disease or event, causing an injury or disease, during service; evidence of current disability; and evidence of a relationship between the current disability and the injury or disease or event, causing an injury or disease, during service. The Veteran was notified that VA would obtain service treatment records, VA records, and records from other Federal agencies, and that he could submit other records not in the custody of a Federal agency, such as private medical records or with his authorization VA would obtain any non-Federal records on his behalf. The notice included the provisions for the effective date of a claim and for the degree of disability assignable. As for content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (38 C.F.R. § 3.159 notice); of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim); and of Vazquez-Flores v. Peake, 580 F.3d 1270 (Fed. Cir. 2009) (evidence demonstrating a worsening or increase in severity of a disability and the effect that worsening has on employment). Further VCAA notice is not required. Where, as here, service connection has been granted and the initial disability rating has been assigned, the claim of service connection has been more than substantiated, the claim has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once the claim of service connection has been substantiated, the filing of a notice of disagreement with the RO's decision rating the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, further VCAA notice under 38 U.S.C.A. § 5103(a) and § 3.159(b)(1) is no longer applicable in the claim for an initial higher rating for PTSD. Dingess, 19 Vet. App. 473, 490; Dunlap v. Nicholson, 21 Vet. App. 112, 116-117 (2007); Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained service treatment records, VA records, records from private medical caregivers, and afforded the Veteran a VA examination in September 2006 and November 2009. The reports of the VA examinations included a review of the Veteran's medical history, including his service treatment records, an interview and an examination of the Veteran, as well as sufficient findings to rate disability. Therefore, the Board concludes that the VA examinations are adequate. 38 C.F.R. § 4.2; see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Posttraumatic stress disorder (PTSD) is rated under Diagnostic Code 9411 under the General Rating Formula for Mental Disorders. The criteria for a 50 percent rating are 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. The criteria for a 70 percent are occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. The criteria for a 100 percent rating are 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. The evidence considered in determining the level of impairment from PTSD under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411 and the General Rating Formula. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994).) 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 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g. suicidal ideation or severe obsessional rituals), or any other serious impairment in social or occupational functioning. GAF score from 51 to 60 represents 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). While the GAF score is relevant evidence, the GAF score alone is neither statutorily nor regulatory controlling in rating a psychiatric disorder, rather the rating is determined by the application of the Rating Schedule, 38 C.F.R. Part 4, as explained above. Neither the number of symptoms, nor the type of symptoms, nor the GAF score controls in determining whether the criteria for the next higher rating have been met. It is the effect of the symptoms, rather than the presence of symptoms, pertaining to the criteria for the next higher rating, that is determinative. The Veteran was provided a VA examination in September 2006. He has been married four times, but has been married to his current wife for 12 years. He has three grown children. He does not see any of his ex-wives, but had a good relationship with his son. The Veteran has worked for over 34 years as an 18 wheel long distance truck driver. In the past, the Veteran very often had nightmares and continues to have nightmares but less frequently. He has trouble falling and then staying asleep. His wife has told him that he talks, mumbles, and often yells in his sleep. He apparently has even choked her in his sleep. He sometimes wakes up scared, but often he does not and will just lie there in his bed. He walks around his house frequently checking the perimeter. The sound and smell of rain, and the smell of burning bodies often remind him of Vietnam. Flashbacks occur about once a week with periods of emotional reactivity to things that bring back thoughts of Vietnam. He talks to very few people about his experiences and does not watch the news of the war. He does not get involved with others socially. He does not go to family gatherings such as his sister's weddings or for funerals. When he returned from Vietnam, he was easily aroused by loud noises and was very startled by people coming up upon unexpectedly. He sits in the back with his back to the wall. He is vigilant and often looks around. The Veteran also reported problems with his anger and blamed the failure of his three prior marriages to the anger issues. The Veteran stated he tries to control his anger. The Veteran drank quite heavily when he came back from Vietnam and also did drugs. He has done neither in the prior year. It has been 20 years since he drank heavily and used drugs. The Veteran has not had any treatment for his mental health symptoms. He has not had any legal problems since leaving the military. On mental health examination the Veteran had a somewhat withdrawn behavior and bland mood and affect. He was able to communicate effectively with the examiner and his speech was normal in rate and volume. The examiner described the Veteran's concentration as fair. There were no panic attacks but the Veteran experienced some suspiciousness. No delusions, hallucinations, elusions, obsessional rituals, suicidal or homicidal thinking were noted. His memory and thinking process were intact. There was no impairment of judgment or abstract thinking. The examiner's diagnosis was ongoing PTSD and assigned a GAF of 50. He noted the Veteran has continued to work, which is to his credit. The Veteran, however, tended to isolate and withdraw when not working, including socially from others because of the PTSD. Even at work, he tends to isolate and withdraw when driving. The Veteran at that time did not pose a threat of persistent danger or injury to himself or others. In January 2008, the Veteran reported occasional flashbacks and his mood was sometimes depressed. He declined medication and wanted counseling. He enjoyed his work, bowling, and going to the gym. No adhedonia was noted. In March 2008, the Veteran reported occasional transient passive suicidal ideation about once a month without a current intention or plan. The mental health provider stated the Veteran's symptom was more in the nature of survivor's guilt. The Veteran had adequate social support with supportive family and friends. The Veteran had problems with anger and memories of the war. He experienced sudden shifts to anger. The Veteran stated he gravitated to truck driving due to the independence and limited interaction with others. The Veteran also reported compulsive checking behaviors. He experienced occasional mild marital stress. The Veteran reported the symptoms significantly damaged his relationship with his son. He also reported anxiety symptoms of restlessness and feeling edgy. He had trouble concentrating and feared of losing control. The Veteran described mood swings that the provider stated were not consistent with primary psychological or maniacal hypomaniac process. He also had symptoms of depression. The Veteran wanted treatment to help control or alleviate symptoms although he declined prescription medication, The evaluator noted the Veteran was cooperative and pleasant. The Veteran did not display psychomotor agitation or retardation or repetitious activities. The Veteran displayed an appropriate speech volume and rate, rhythm, and intensity. He was alert and oriented and presented an anxious mood with an appropriate range of affect. His thought processes are coherent, logical, and goal directed. There were no flight of ideas, loose associations, thought blocking, hallucinations, or delusions. The Veteran had fair insight and judgment. The GAF was 55. In another evaluation in March 2008, the Veteran found crowds to be a trigger, making him uncomfortable. He avoids crowds or activities with lots of people. He feels he is always on guard and will check and recheck doors and windows at home. He checks the yard at night. He has a very short temper and easily becomes upset. He is also angry that he survived but others did not make it back. He felt distant from others. He had a routine that helped him cope until the recent wars in Afghanistan and Iraq. His symptoms then increased. He currently works driving a truck for Wal-Mart. He has had one DUI and many public intoxication arrests. His sleep is restless and he tosses and turns for a total sleep of about 5 hours a night. He rarely has nightmares but will wake up with a cold sweat, rapid heartbeat, and heavy breathing. He does not remember the dreams. In the mental health examination, the Veteran was pleasant, cooperative and attentive. His affect was appropriate and within normal limits, He was alert and oriented and his memory and concentration was good. The evaluator found no thought disorders or delusions and his judgment and insight was good. While there were frequent suicidal and homicidal ideations, the Veteran has never acted upon them. The diagnosis was PTSD and major depressive disorder. The GAF was 59. In April 2008, the Veteran started group therapy for PTSD. In January 2009, the Veteran reported anxiety symptoms. He felt very closed in and did not like crowds and noise. He will get tremulous and short of breath because he feels people are going to attack him. Breathing exercises help sometimes. And he meditates with music. Flashbacks are very rare. He also had a depressed mood and mood swings. He avoids news of the war and sometimes asks why he came back when others didn't. He did not have adhedonia and goes to the gym or walking by himself. Falling asleep was still difficult but he rarely gets nightmares. In May 2009, the Veteran completed PTSD classes. He did not sign up for or request additional classes or referrals at the end of the original classes nor had he received any medications. In June 2009, however, in a statement to VA, the Veteran indicated his plan to continue going to classes and receive any medication as needed. In a VA examination in November 2009, the Veteran had not re-started group therapy, but was awaiting an assignment. The Veteran stated he struggled with his marriage and often wanted to take off and leave. He felt angry and pressured with his wife. He had no relationship with his son and does not get along with the son. He does have some acquaintances and social outlets with his wife such as movies, dancing, and church but does not enjoys these activities because he becomes moody and sad. He does enjoy exercising, walking, and being alone in nature. The Veteran stated he had no friends of his own and no one he could confide in. The Veteran reported he will cut people off in traffic and will chase people down in traffic due to road rage. He has received reprimands because of road rage. The examiner stated the Veteran functions marginally, but it is not clear from the report if this was a conclusion of the examiner or the Veteran. There were no issues associated with alcohol or drug use. The Veteran sleeps two to three hours a night and then remained lying in bed. He is tired and cannot concentrate the next day. For example, he will miss his exit. This causes him to become angry and frustrated. The Veteran did not have obsessive or ritualistic behavior. The Veteran was hyperactive, restless, and tense during the examination. He had spontaneous, rapid, and coherent speech. His affect was appropriate but he was tearful. He had an anxious, hopeless, dysphoric mood. There was attention disturbance. The Veteran was oriented and had unremarkable thought process. He had suicidal ideation, but no delusions. The Veteran understood the outcome of his behavior and that he had a problem. His memory was normal. The examiner determined the Veteran's PTSD symptoms had a severe affect on shopping, and a moderate affect on household chores (due to motivation), travelling, driving, and recreational activities. It had no effect on the activities of daily living needed to take care of himself and no effect on the Veteran engaging in sports and exercise. The VA examiner diagnosed chronic severe PTSD which resulted in anger/irritability, isolation, sadness, recurrent thought, anxiety, and sleep disturbance causing difficulty in social interactions, recreational activities and occupation. The Veteran was capable of handling his financial affairs. The examiner noted the Veteran had continued to be employed full time more than 20 years and had not lost any time from work during the last 12 month period. His occupational functioning has been affected by inappropriate behavior. There had been no change in the functional status and quality of life of the Veteran since the VA examination in 2006. The Veteran had a fair prognosis and the GAF was 57. The examiner concluded the Veteran's PTSD resulted in deficiencies in judgment (anger/road rage), thinking (suicidal thinking), family relationships (anger with his wife, estrangement from his son), work (the reprimands), and mood (anger, recurrent thoughts, and survivor guilt). The examiner also stated the Veteran had reduced reliability and productivity due to PTSD symptoms pointing to the symptoms of anger/road rage, recurrent thoughts, and survivor guilt causing a sad mood, reprimands for behavior while driving, and suicidal thoughts. After a review of the record, the Board has determined that the overall effect of the PTSD constellation of symptoms does not more nearly approximate or equate to the criteria for the next higher rating, namely, a 70 percent rating due to occupational and social impairment with deficiencies in most areas, such as family relations, judgment, thinking, or mood. Instead, the symptoms due to PTSD has resulted in occupational and social impairment with reduced reliability and productivity The Veteran has problems with re-experiencing symptoms, avoidance symptoms, survivor's guilt, detachment, and anger issues. While it appears the anger and detachment issues cause the most problems, the avoidance or re-experiencing symptoms and survivor's guilt, while affecting his quality of life, do not appear to cause functional impairment. As to the anger and detachment, the Veteran appears to be able to maintain his employment as a truck driver even with some problems with directing anger towards other drivers. He has sleep difficulties with resulting symptoms, but again, the record before the Board demonstrates the severity does not affect his overall occupational functioning. It has caused the Veteran to miss exits when making deliveries, but apparently it has not occurred with a frequency or severity that he is still able to perform his job duties to his employer's satisfaction. It has also affected his family relationships as he has had three failed marriages and his PTSD has put additional stress on his current marriage, but, he is still married and has been married for approximately 15 years. The Veteran had a good relationship with his son at the time of the September 2006 VA examination, but they are now estranged. There is no evidence in the file, however, as to why the two are estranged and the Board is only left to speculate that it is due to PTSD. The Board also notes that he has no one he considers a friend. He does engage in some activities with his wife such as movies, church, and dancing, although he does not enjoy them. Nevertheless, there are activities he enjoys such as exercising or walking. The examiner did not record problems with judgment, thinking, or mood other than some depression and survivor's guilt. While the Veteran suffers from depression, that symptom has not played a role in his occupational functioning, only his social functioning. The Board is aware that the VA examiner in November 2009 concluded that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. The same examiner, however, used the same symptoms to state the Veteran had reduced reliability and productivity in occupational and social functioning. In consideration of PTSD symptoms, the examiner assigned a GAF of 58, which suggest only moderate impairment. He also stated that the symptoms had a moderate or no affect in most activities except shopping, which relates to his anxiety symptoms and crowds. The same examiner also noted the Veteran had a fair prognosis, which indicates the symptoms are not of a level of severity that improvement is still possible. He also concluded that overall functioning had not changed since the VA examination in September 2006. The Board's decision is also informed by, although not totally based upon, the similar assessments made by the September 2006 VA examiner and the Veteran's mental health providers. They have also assigned similar GAF scores with the lowest score of 50 assigned at the VA examination in September 2006. His scores since that time have been higher. Reconciling the various reports into a consistent disability picture, the present picture of the disability that emerges is that a material change in the overall severity of the disorder has not been demonstrated. At best, while there has been some fluctuation in the symptoms of PTSD, notably, that it may have affected his relationship with his son, his symptoms have not reached a level of severity and do not more nearly approximate occupational and social impairment with deficiencies in most areas. Instead, overall, the symptoms of PTSD affect the Veteran occupationally and socially, but have resulted in a disability picture more consistent with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily. It appears that the Veteran has successfully, although not perfectly, maintained his current occupation that allows him to work in a more solitary setting. The symptoms that are attributable to posttraumatic stress under DSM- IV, such as anger, intrusive thoughts, anxiety, are not the equivalent to occupational and social impairment that warrants a 70 percent rating as the Veteran is able to maintain his current occupation and some limited social relationships and activities. Addressing some of the symptoms mentioned for a 70 percent rating, the Veteran may have impaired impulse control such as unprovoked irritability that has manifested itself with the road rage incidents and strained family relationships. There have not, however, been any periods of violence as referred to in the schedular criteria. The Veteran also has also been willing to use coping strategies such as walking away, deep breathing, and mediation to music. The Veteran has had what he describes as suicidal thoughts, but has also stated he would never act upon them and his caregivers believe the Veteran's statements are really indications of survivor's guilt, not suicidal ideation. The Veteran has engaged in activities such as checking his house several times a night but there is no indication of obsessional rituals which interfere with routine activities. The Board's review of the evidence has not demonstrated intermittently illogical obscure or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene. The Veteran has demonstrated difficulty in adapting to stressful circumstances and has difficulty in to establishing and maintaining effective relationships, but for the reasons expressed above, the level of severity has resulted in reduced productivity and has not resulted in the higher level of severity mentioned in the criteria for a 70 percent rating. The Board has considered that the symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). As such, the Board notes that the Veteran experiences other symptoms that are not listed in the criteria, but may reflect the severity of his PTSD. These include, but are not limited to difficulty sleeping, intrusive thoughts, reexperiencing, avoidance, and hyperarousal. Specifically, the Board has also considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with reduced reliability and productivity, due to such symptoms as: anxiety, avoidance, reexperincing the stressors, avoidance behaviors, and sleep impairment. See Mauerhan, 16 Vet. App. 436. As noted above, the Board finds that these symptoms, their level of severity, and effect do not represent a disability picture indicating deficiencies in most areas such as working, school, family relations, judgment, thinking, or mood. While the Veteran has apparently been reprimanded at work, he continues to work full time as a long haul 18 wheeler truck driver for well over 30 years and as indicated that he had lost no time at work during the previous 12 months due to his PTSD. This is an indication that the Veteran does not have occupational impairment with deficiencies in most areas that would warrant a 70 percent rating. The overall effect of the constellation of symptoms results in moderate symptoms as evidenced by GAF scores in the range of the 50s by VA examiners and caregivers. A GAF score in the range of from 51 to 60 represents moderate difficulty in social and occupational (e.g., few friends, conflicts with peers or co-workers), which was also consistent with the Veteran's symptomatology. As such, these scores reflect a disability with moderate symptoms or some difficulty in social, occupational, or school functioning but generally functioning pretty well, and had some meaningful interpersonal relationships. In sum, the preponderance of the evidence is against an initial evaluation higher than 50 percent for PTSD and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here in this case, the rating criteria for PTSD describe the disability levels and symptomatology. The Board has considered the Veteran's lay statements regarding his disability. The Veteran describes, as to those symptoms related to service connected PTSD, his reliving the experiences, avoidance behaviors, anxiety, anger, and in the examination, also reported his impairment at work and with others. The Board has determined that such impairment of functioning is already encompassed in the ratings criteria by rating according to the General Rating Formula for Mental Disorders. In other words, the Veteran does not experience any symptomatology not already encompassed in the Rating Schedule. Total Disability Rating for Compensation Based on Individual Unemployability During the appeal period, the Veteran has not expressly raised and the record does not reasonably raise a claim for total disability rating for compensation based on individual unemployability. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (in a claim for increase, where the Veteran expressly raises a claim for a total disability rating on the basis of individual unemployability or the claim is reasonably raised by the record, the claim is not a separate claim, but a part of a claim for increase). The Veteran is employed as a truck driver and has been some employed for now nearly 40 years. Therefore, in the circumstances of this case, the Board declines to take jurisdiction over a total disability rating claim. ORDER Entitlement to an initial evaluation higher than 50 percent for PTSD is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs