Citation Nr: 1321463 Decision Date: 07/03/13 Archive Date: 07/12/13 DOCKET NO. 07-03 993 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial evaluation higher than 50 percent for posttraumatic stress disorder (PTSD) for the period since December 21, 2006. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran, his spouse, and his friend, G.B. ATTORNEY FOR THE BOARD Bridgid D. Cleary, Counsel INTRODUCTION The Veteran served on active duty from October 1966 to July 1968. This matter has come before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection form PTSD with an initial 30 percent evaluation, effective August 20, 2003. In a January 2007 rating decision, this initial evaluation was increased to 50 percent, effective December 21, 2006, the date of a VA PTSD examination. The Veteran continued his appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993)(a claimant is deemed to seek the highest rating allowable for a disability unless otherwise indicated). The Veteran testified at a Travel Board hearing in January 2009 before a Veterans Law Judge who is no longer at the Board. During the hearing, the Veteran submitted additional evidence with a waiver of initial RO consideration. See 38 C.F.R. § 20.1304. A transcript of the hearing is associated with the claims file. VA regulations require that the Judge who conducts a hearing on an appeal must participate in any decision made on that appeal. 38 U.S.C.A. § 7107(c); 38 C.F.R. § 20.707. In a letter dated in October 2011 the Veteran was notified of his options. He responded, indicating that he did not want another hearing. Therefore, the Board will consider his case on the evidence of record. In April 2009, the Board remanded this case for further development. In August 2012, the Board denied the issue of entitlement to an initial evaluation higher than 30 percent for PTSD for the period prior to December 21, 2006, and remanded the portion currently on appeal. This appeal was processed in part by using the Virtual VA paperless claims processing system. The documents contained in this system, including the hearing transcript, were reviewed in conjunction with this appeal. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDING OF FACT Since December 21, 2006, the Veteran's PTSD has been characterized by sleep problems, nightmares, flashbacks, irritability, hypervigilance, and hyperstartle response, which have resulted in occupational and social impairment and reduced reliability, but not deficiencies in most areas such as work, family relations, judgment, thinking, and mood. CONCLUSION OF LAW Since December 21, 2006, the criteria for an initial evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veteran's increased rating claim for PTSD arises from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional 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). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board has reviewed the electronic evidence contained in the Veteran's Virtual VA folder as well as the paper file. These files together comprise the claims file. The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a January 2009 hearing before a Veterans Law Judge. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. In compliance with the Board's April 2009 remand, VA obtained outstanding VA treatment records and provided the Veteran with a medical examination in September 2009. This examination contained all information needed to rate the disability. Indeed, the examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. Therefore, this examination is adequate for VA purposes. Likewise, in compliance with the Board's August 2012 remand, VA provided the Veteran with a medical examination in October 2012. This examination contained all information needed to rate the disability. Indeed, the examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. Therefore, this examination is adequate for VA purposes. Thus VA has complied with the April 2009 and August 2012 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). The United States Court of Appeals for Veterans Claims (Court) has held that provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). At the hearing the Veterans Law Judge identified the issue, sought information as to treatment to determine whether all relevant records had been obtained, and sought information as to any changes in the disability since the last examination. Ultimately the claim was remanded for a new examination. The Board thereby met the duties imposed by 38 C.F.R. § 3.103(c)(2) as interpreted in Bryant. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with these duties; they have not identified any prejudice in the conduct of the Board hearing. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis In this case, the Veteran is seeking a higher initial evaluation than 50 percent for posttraumatic stress disorder (PTSD) for the period since December 21, 2006. Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Under that General Rating Formula, a 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. The next higher evaluation of 70 percent 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. Id. 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. Id. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). Id. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection, and consideration of the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet App 119, 125-26 (1999). The Veteran underwent a VA examination on December 21, 2006. At that time, the Veteran was fully-oriented, cooperative, and friendly. The Veteran was clean and casually dressed with a large tattoo on his scalp. His psychomotor activity was unremarkable. His speech was spontaneous and he was very talkative. His affect was appropriate and his mood was dysphoric. His attention was intact. His thought process was verbal and his thought content was unremarkable. He understood the outcome of his behavior. His intelligence was average. He understood that he had a problem. The Veteran had sleep apnea and used a CPAP machine. He got up two or three times per night. The Veteran had no inappropriate behavior, obsessive/ritualistic behavior, panic attacks, suicidal thoughts, homicidal thoughts, episodes of violence, or problems with activities of daily living. The Veteran was able to maintain personal hygiene and had good impulse control. His memory was normal. His PTSD symptoms included recurrent and intrusive recollections of the traumatic event and intense psychological distress at internal or external cues that symbolize or resemble an aspect of the traumatic event about twice a week. On a daily basis, he avoided thoughts, feelings, or conversations associated with the trauma, and activities, people, or places that arouse recollections of the trauma and had markedly diminished interest or participation in significant activities. Additionally, he reported difficulty falling or staying asleep, irritability or outbursts or anger, hypervigilance, and exaggerated startle response which varied in frequency based on the cue but had been moderately severe since his last examination. The Veteran's mother was in poor health and had recently moved in with the Veteran's brother. He was angry at his sister-in-law. The Veteran lived with his third wife and reported that he kept in touch with his children. Outside of the family, the Veteran reported having one friend who also served in Vietnam. He reported no hobbies beyond watching television. He raked leaves and pine straws. The Veteran denied a history of suicide attempts or violence/assaultiveness. He reported that he drank beer, but had given up whiskey. The Veteran did not report drug use, but urinalysis was positive for THC (marijuana). The Veteran was unemployed for many years due to his back disability. He stated that he would occasionally pick up odd jobs to supplement his income. He was found to have occupational and social impairment with reduced reliability and productivity due to his PTSD symptoms. Specifically, the examiner noted that the Veteran preferred to be away from others to avoid conflict and that this may affect his productivity. While a veteran's rating on the Global Assessment of Functioning (GAF) scale is not dispositive, the Board notes that the examiner assigned the Veteran a GAF score of 55, which 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 coworkers). See DSM- IV. Prognosis for improvement was good. With regard to the Veteran's alcohol and marijuana use, the examiner determined that this was not self-medication of the Veteran's PTSD. The examiner further noted that the consequences of alcohol dependency are often seen in family and interpersonal relationships and occupational functioning and that even moderate alcohol use could interfere with treatment for PTSD. The Veteran's wife's September 2007 letter notes the Veteran's symptoms of depression, non-communication with his family and friends, mood changes, nightmares, cold sweats, crying spells, flashbacks, insomnia, and roaming thoughts. VA outpatient treatment records from April 2007 and October 2007 note the Veteran's PTSD symptoms of nightmares, a low tolerance of others in social settings, sensitive startle response to noise, agitation, anger management, and depression. He was sleeping better with his CPAP machine. His mood was fairly stable and he was getting along with his wife. He stated that his dog was his best friend. His daughter had recently moved home. The Veteran stated that he would occasionally have a few beers when he attended American Legion meetings, but he had not had marijuana in several weeks. The Veteran displayed no psychomotor, thought process, or thought content abnormalities. His eye contact was good. He was fully oriented. His memory was intact. He denied suicidal and homicidal ideation, intent, or plan. There was no evidence of response to internal stimuli. His mood was good and his affect was even with his mood. He was pleasantly talkative, not tearful. His judgment and insight were fair. The Veteran was assigned a GAF score of 56, which again which represents moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM- IV. In his November 2007 VA Form 9, the Veteran state that he experienced hallucinations, suicidal thoughts, and depression due to his PTSD symptoms. He further stated that he was unemployable due to his heart condition. In her November 2007 letter, the Veteran's wife state that he would not socialize, showed a general lack of interest, and was quick tempered. In a March 2008 statement, the Veteran stated that he was unemployable due to his PTSD medication. VA treatment records from March 2008 note that the Veteran reported a "pretty good" mood despite admitting to isolating and having a poor tolerance for frustration and crowds. His is sleeping adequately with medication; otherwise he has nightmares and gets only two hours of sleep. He is able to complete tasks at home and regularly visits with his wife and children. He was fully oriented. No involuntary movements were noted. Grooming, attire, and hygiene were adequate. His mood was "pretty good," but with constricted affect. He denied suicidal or homicidal ideation, and hallucinations. His thought process was logical, linear, and goal-directed with relevant and appropriate content. There was no evidence of thought disorder or psychosis. Speech was clear an within normal limits for rate, volume, and prosody. His intelligence was estimated to be average. Social judgment and insight into his condition seemed adequate. His memory was intact. The Veteran was assigned a GAF score of 58, which represents moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV. In her June 2008 statement, the Veteran's wife reported his symptoms of constant outbursts in Vietnamese; cursing; negative thoughts and attitudes towards strangers, friends, and family; abuse towards dog and spouse; daily visual hallucinations of bugs crawling; daily auditory hallucinations of helicopters and gunfire; talk of suicide; inability to maintain personal hygiene; social isolation; memory problems; sleep problems; flashbacks triggered by loud noises; and dependence on alcohol and VA-prescribed medication. VA treatment records from July 2008 note that the Veteran was casually dressed with adequate hygiene. His mood was initially anxious, but lightened some as the session progress. His affect was congruent and appropriate. He was alert and fully oriented. His speech was fluent and goal-directed. His memory appeared grossly intact. There was no evidence of a thought disorder; no suicidal or homicidal ideation. He reported losing touch with his brother and attributed this to his sister-in-law. He maintained contact with three of his five children. He stated that his wife was the best part of his life. He also enjoyed his dog. He was not compliant with his PTSD medication as he felt it caused erectile dysfunction. VA treatment records from August 2008 note the Veteran's complaints of hyperirritability, hypervigilance, hyperstartle response, daily anxiety and apprehensiveness, insomnia, vivid memories, nightmares, flashbacks, feelings of guilt, low frustration tolerance, road rage, social isolation, and intolerance of crowds. The Veteran reported being a loner, but that his wife and his dog were the most important things in his life. The Veteran's grooming and hygiene were good. He was fully oriented. He sat quietly with no movement disorder. There was no evidence of a psychotic thought process, loosened associations, flight or ideas, tangential or circumstantial thinking, hallucinations, delusions, obsessions, compulsions, or destructive ideations directed at himself or others. Indeed, the Veteran reported that both his father and grandfather had committed suicide and that he felt it was the cowardly way out and never thought about it. His mood was apprehensive at first, but pleasant. His memory was intact. His intellectual functioning was within the normal to high-normal range. His insight and judgment for routine life events was good. The Veteran was assigned a GAF score of 60, which represents moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM- IV. VA treatment records from September 2008 note that the Veteran had given up drinking whiskey and was taking new medication. His mood had improved and he had lost weight. He stated that his wife felt like she had her husband back. He was not in contact with his brother, which he attributed to his sister-in-law's influence, but he was enjoying his four-year-old grandson and was expecting another grandson in the coming months. He reported intrusive thoughts about Vietnam. VA treatment records from November 2008 show that the Veteran was compliant with his medication and felt he was getting a good response. These VA treatment records from September 2008 and November 2008 show that the Veteran's grooming and hygiene were good. He was fully oriented. He sat quietly with no movement disorder. There was no evidence of a psychotic thought process, loosened associations, flight or ideas, tangential or circumstantial thinking, hallucinations, delusions, obsessions, compulsions, or destructive ideations directed at himself or others. His thoughts were logical, coherent, and linear. His mood and affect were pleasant and appropriate. His memory was intact. His intellectual functioning was within the normal to high-normal range. His insight and judgment for routine life events was good. The Veteran was assigned a GAF score of 65, indicating some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. See DSM-IV. At his January 2009 hearing, the Veteran reported waking up at night to "pull guard duty" and lack of motivation during the day. He had been prescribed a "mood pill" for his symptoms, but did not take it because he did not believe it worked and because it resulted in erectile dysfunction. The Veteran reported homicidal thoughts towards his sister-in-law, who he blamed for his brother's perceived mishandling of his parents' estate. He also reported visual hallucinations of bugs crawling. He indicated that he did not take regular showers, despite his wife's requests. He reported forgetfulness, including an incident where he went to the store without his teeth. Television coverage of the current wars would cause flashbacks. The Veteran lived with his wife of 23 years. They argued and the Veteran reported a heated argument with his stepdaughter that nearly became physical. When asked, the Veteran stated that he felt he got along well with his children. He reported having two friends, one who accompanied the Veteran to his hearing and another from childhood. He also stated that he got along well with his dog and that occasionally he would go out to the American Legion for three of four beers with his friend. The Veteran was unemployed. His former employer had submitted a letter stating that the Veteran could not get along with others and started altercations and fights. See January 2009 letter from J.P.L. The Veteran reported being fired from his last job because of a back injury and problems getting along with his superintendent. The Veteran's wife also testified at the January 2009 hearing. Her testimony at this hearing is essentially duplicative of the statement she submitted at that time. She testified that she was the Veteran's third wife and that they had been together for 34 years and in the last two he had become abusive in that he would rant, rave, cuss, throw things, and punch holes in walls, but he was not physically abusive towards her. He did not want to do anything or be around anyone. She stated it was "like he despises our children." He had not acknowledged the birth of his grandson. She testified that the Veteran's problems with alcoholism and marijuana were in the past and he would occasionally drink with his buddy from Vietnam, who also testified, but that they would only finish a six pack of beer between them in three days. The Veteran had lost interest in his dog. She related changes in the Veteran's behavior to the medicine used to treat his PTSD. The Veteran's friend, G.B., testified on his behalf at the January 2009 hearing. He stated that the conversations between the Veteran and himself were centered around their Vietnam experiences. He denied ever arguing with the Veteran. He stated that he was rated 100 percent for PTSD and felt the Veteran's symptoms were worse than his. G.B. testified that the Veteran experienced a flashback every time he heard a firecracker. They avoided crowds and instead socialized on the Veteran's back porch. In July 2009, the Veteran underwent another VA examination. The Veteran's claims file was not reviewed in connection with this examination. The Veteran reported that he had been married to his third (current) wife for 23 years and described the marriage in positive terms. He reported a close relationship with his son from his second marriage and that he had two close friends. He watched television, performed yard work, ate out occasionally, and sat on his back porch feeding squirrels. The Veteran denied a history of suicide attempts or violence/assaultiveness. He reported that he drank beer three or four times a week, a pint at a time. He also reported smoking cannabis every chance he got. He was casually dressed and attentive to the examiner. His psychomotor activity was unremarkable. The Veteran's speech was unremarkable, spontaneous, clear, and coherent. His affect was full. With regard to his mood, he reported an earlier argument with his wife that had made him "pissed off" that morning. He was fully oriented. His thought process and content were unremarkable. He understood the outcome of his behavior. His intelligence was average. He partially understood that he had a problem. He reported a sleep impairment resulting in 6 to 7 hours of interrupted sleep each night that left him with poor energy. He denied hallucination, delusions, obsessive behaviors, panic attacks, suicidal or homicidal ideation, episodes of violence, and problems with activities of daily living. His impulse control was fair. He was able to maintain minimum personal hygiene. His memory was normal. His PTSD symptoms included recurrent and intrusive recollections of the traumatic event, intense psychological distress at internal or external cues that symbolize or resemble an aspect of the traumatic event, and physiological reactivity to internal or external cues that symbolize or resemble an aspect of the traumatic event. The Veteran avoided thoughts, feelings, or conversations associated with the trauma, and activities, people, or places that arouse recollections of the trauma and had markedly diminished interest or participation in significant activities and reported feelings of estrangement from others. Additionally, he reported difficulty falling or staying asleep, difficulty concentrating, hypervigilance, and exaggerated startle response. The Veteran was unemployed due to his verbal aggression towards coworkers, but stated that he was looking for work. The examiner found that the Veteran's PTSD symptoms were not severe enough to prevent employment. Socially, the Veteran had a good marriage and two close friends, which suggested mild social detachment. With regard to the additional diagnoses of alcohol and cannabis dependence, the examiner noted that the intrusive memories and nightmares were associated with PTSD, but the problems with sleep, concentration, and irritability could be due to his substance abuse as these disorders likely exacerbate social withdrawal and irritability/anger. The examiner assigned the Veteran a GAF score of 60, which represents moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM- IV. Prognosis for improvement was fair. Ultimately, the examiner found that the Veteran's PTSD resulted in occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks, but generally satisfactory functioning. VA outpatient treatment records from September 2009 note the Veteran's reported alcohol consumption as three to four drinks two or three times per week. the Veteran reported hyperirritability and frequent anger, but denied recent flashbacks or nightmares. The Veteran reported continued feelings of anger towards his sister-in-law stating that he would "like to cut her head off," but noting that he was not seriously going to try. The psychiatrist found that the Veteran was not a threat to himself or others. The Veteran's grooming and hygiene were fair to good. He was fully oriented. He sat quietly with no movement disorder. There was no evidence of a psychotic thought process, loosened associations, flight or ideas, tangential or circumstantial thinking, hallucination, delusions, obsessions, compulsions, or destructive ideations directed at himself or others. His thoughts were logical, coherent, and linear. His mood was calm. His affect was neutral in amplitude. His memory was intact. His intellectual functioning was within the normal range. His insight and judgment for routine life events was adequate. The Veteran was assigned a GAF score of 60, which again which represents moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM- IV. In October 2012, the Veteran underwent another VA examination in conjunction with this appeal. At that time, the Veteran's symptoms included anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation or mood. He lived with his second wife of 35-40 years. They had adult one son who lived in South Carolina. The Veteran had last visited his son seven or eight years prior. He reported having one friend, also a Vietnam War veteran. A friend from childhood had recently died. Both of his parents and his older brother were dead. He had a three year old grandson. The Veteran denied homicidal and suicidal ideation. The Veteran stated that he was on Social Security disability for his back and had not worked in 15 years. He reported drinking alcohol every day and smoking $150 worth of marijuana per month. The Veteran was diagnosed with PTSD, alcohol dependence, and cannabis dependence. The Veteran is not service connected for alcohol or cannabis dependence. The examiner indicated that it was possible to differentiate which symptoms were attributable to which disability and stated that the alcohol and cannabis dependence contributed to anxiety and mood symptoms as well as his social and occupational impairment. Ultimately, this examiner found that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. Based on the above, the Board concludes that the preponderance of the evidence is against the assignment of disability rating in excess of the assigned 50 percent for the Veteran's PTSD as of December 21, 2006. During this period, the Veteran's PTSD has been characterized by sleep problems, nightmares, flashbacks, irritability, hypervigilance, and hyperstartle response. These symptoms suggest occupational and social impairment with reduced reliability and productivity, as required for a 50 percent evaluation. See 38 C.F.R. § 4.130, Diagnostic Code 9411. These symptoms, however, are not akin to the occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood necessary for a 70 percent disability evaluation. See id. Indeed, despite difficulty in his interpersonal relationships, the Veteran has maintained relationships with some family members and two friends (until the unfortunate passing of one of them). Similarly, his thinking and judgment have been intact and his mood has oscillated from dysphoric to "pretty good." Throughout the appeals period, his GAF score has remained at or above 55, which represents moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV. While the Veteran's wife has provided lay evidence of suicidal ideation, the Veteran himself has consistently denied suicidal ideation during treatment and at his examinations. Likewise, although the Veteran's wife's statements and the January 2009 testimony indicate that the Veteran has difficulty maintaining his personal hygiene, such difficulty has not been noted during his regular treatment and scheduled examinations. Instead, those records consistently note that he is in fact able to maintain his personal hygiene. He has not displayed any other symptom that would support a finding of occupational and social impairment with deficiencies in most areas. In other words, he has not experienced problems similar to those contemplated by the 70 percent rating, like 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; spatial disorientation; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships. Thus, the Board concludes that the preponderance of the evidence is against the assignment of an initial rating in excess of 50 percent for the Veteran's PTSD from December 21, 2006. 38 C.F.R. § 4.7. The Board must also determine whether the schedular evaluation is inadequate, thus requiring that VA refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation is not inadequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected disability, such as additional social and/or occupational impairment, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorder. As the rating schedule is adequate to evaluate the disability, referral for extraschedular consideration is not in order. In addition, the Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has not specifically raised the issue of entitlement to a TDIU as a result of his PTSD. See 38 C.F.R. § 4.16. A TDIU was denied in a January 2008 rating action and not appealed. In the event that there is anything in the record that implicitly raises a claim of TDIU, review of the overall evidence does not reflect that the Veteran's service-connected PTSD alone precludes employment. The Veteran reported not working due to his back disability in December 2006; subsequently he has claimed that he is unable to work due to his PTSD, but this is not suggested in the examination reports or outpatient treatment records. Thus, entitlement to a TDIU due to PTSD is not warranted. ORDER An initial evaluation higher than 50 percent for posttraumatic stress disorder (PTSD) for the period since December 21, 2006, is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs