Citation Nr: 1322665 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 09-21 508 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an initial disability rating higher than 30 percent for posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran served on active duty from October 2004 to February 2006, with additional unverified prior active and inactive service. This appeal to the Board of Veterans' Appeals (Board) is from a February 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for PTSD and assigned an initial 30 percent rating for it retroactively effective from July 30, 2007, the date of receipt of this claim. The Veteran wants a higher initial rating for his PTSD. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a Veteran appeals an initial rating, VA adjudicators must consider whether to "stage" the rating, meaning assign different ratings at different times since the effective date of the award if there have been variances in the severity of the disability, in other words, times when it has been worse than at others). In September 2012 the Board remanded this claim to the RO via the Appeals Management Center (AMC) for further development - including especially to obtain all outstanding evaluation or treatment records since 2007, notably those from the local Vet Center in Houston, Texas, and to have the Veteran undergo another VA compensation examination reassessing the severity of his PTSD. The AMC completed this requested additional development, but continued to deny the claim for a higher initial rating for the PTSD, so this claim is again before the Board. FINDING OF FACT The Veteran's PTSD is manifested by anxiety, irritability, sleep disturbance, nightmares, social isolation, intrusive memories, hyperstartle response, hypervigilance, and occupational and social impairment; he generally functions adequately without problems with speech, judgment, or insight. CONCLUSION OF LAW The criteria are not met for an initial disability rating higher than 30 percent for the PTSD. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.125-4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA enhanced VA's duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5100, 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 VCAA also redefined the obligations of VA with respect to the duty to assist the veteran with the claim. Id. The Board finds that VA satisfied these obligations. Duty to Notify VA has a duty to notify the Veteran of any information and evidence needed to substantiate and complete a claim upon receipt of a complete or substantially complete application. 38 U.S.C.A. §§ 5102, 5103. The Board concludes that the letters dated in August 2007, October 2012, November 2012, and December 2012 that were sent to the Veteran adequately apprised him of the information and evidence needed to substantiate the claim and of his and VA's respective responsibilities in obtaining this supporting evidence. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), the notice must: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will obtain; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). See also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). A claim of entitlement to service connection consists of five elements: (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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). The Court has held that notification of what evidence is necessary to substantiate the claim under 38 U.S.C.A. § 5103(a) therefore requires notice of all five of these elements, so including concerning the "downstream" disability rating and effective date in the event the underlying claim for service connection is granted. See id. at 486; Quartuccio, 16 Vet. App. at 187. The Board finds that VA has met these duties with regard to the claim adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in August 2007, October 2012, November 2012, and December 2012 fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the Veteran received notice of the evidence needed to substantiate his claim, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Board also recognizes that, ideally, VCAA notice should be provided prior to an initial decision on a claim by the Agency of Original Jurisdiction (AOJ), which in this instance is the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Written notice was provided in August 2007, prior to the appealed from rating decision, along with the subsequent notice provided in October 2012, November 2012, and December 2012, after the decision that is the subject of this appeal. In addition, with respect to the Dingess requirements, in the aforementioned letters, the Veteran was provided with notice of what type of information and evidence was needed to substantiate his increased-rating claim; however, he was not provided with notice of the type of evidence necessary to establish an effective date for the rating. Despite any timing deficiency under Pelegrini in the sense that not all of those notices preceded the initial adjudication of the claim, and despite inadequate notice under Dingess, the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). In this regard, as the Board concludes below that the criteria for an initial disability rating higher than 30 percent for the PTSD have not been met, any questions as to the appropriate effective date to be assigned are rendered moot. The Board also notes that the case was readjudicated in a March 2013 supplemental statement of the case (SSOC) and, as such, the Veteran has not been prejudiced thereby. See Bernard, supra. This readjudication served to rectify ("cure") the timing defect in the provision of the aforementioned notices. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). Even if notice was not provided prior to initially adjudicating a claim, or if provided it was inadequate or incomplete, VA need only provide all necessary notice and then, after giving the Veteran opportunity to submit additional evidence and/or argument in response, readjudicate the claim, such as in a statement of the case (SOC) or supplemental SOC (SSOC). This readjudication rectifies ("cures") the timing defect in the provision of the notice because it preserves the intended purpose of the notice in that the Veteran is still given ample opportunity to participate effectively in the adjudication of the claim. Id. During the pendency of this appeal, the Court issued a decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), holding that VA needed to provide a greater degree of specificity with respect to notice of the criteria necessary for an increased rating. However, this decision later was vacated by the United States Court of Appeals for the Federal Circuit (Federal Circuit Court), indicating VA need only provide generic notice and need not apprise the Veteran of alternative diagnostic codes or to present evidence as to how his disabilities affect his daily-life experiences. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). Also, since this claim for a higher initial rating for PTSD is a "downstream" issue arising out of the granting of service connection for this disability, Vazquez notice was never required. See VAOPGCPREC 8-2003 (Dec. 22, 2003). In this circumstance, the claim as it arose in its initial context, for service connection, has been more than substantiated, it has been proven, thereby rendering § 5103(a) notice no longer required because the initial intended purpose of the notice has been served. See Goodwin v. Peake, 22 Vet. App. 128 (2008). So once a Notice of Disagreement (NOD) has been filed contesting the "downstream" issue of the initial rating assigned for the disability, the notice requirements of 38 U.S.C. §§ 5104 and 7105 regarding a rating decision and statement of the case (SOC) control as to the further communications with the appellant, including as concerning what evidence is necessary to establish a more favorable decision with respect to this downstream elements of the claim. Id.; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007). And the Veteran was provided this required SOC, also an SSOC discussing this downstream claim for a higher initial rating for his PTSD, citing the applicable statutes and regulations, and providing reasons and bases for assigning an initial 30 percent rating and no greater rating. He therefore has received all required notice concerning his claim. Moreover, he has not alleged any undue prejudice in the notice provided, either in terms of the timing or content of it. And as the pleading party attacking the agency's decision, he has this burden of proof of not only establishing the occurrence of such error, but also, above and beyond that, of showing how it is unduly prejudicial, meaning outcome determinative of his claim. He has not made any such pleading or allegation. See Shinseki v. Sanders, 129, S. Ct. 1696 (2009). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence, and the Veteran received VA examinations in January 2008 and January 2013, which were thorough in nature and adequate for the purposes of deciding this claim. The aforementioned VA examinations revealed findings that are adequate for rating the Veteran's PTSD. Thus, the Board finds that the medical evidence of record is sufficient to resolve this appeal; VA has no further duty to provide an examination or medical opinion. 38 C.F.R. §§ 3.326, 3.327. The Board also notes substantial compliance with the remand directives in its previous remand in September 2012. Stegall v. West, 11 Vet. App. 268 (1998). In the September 2012 remand, the Board noted that according to the Veteran, he had been receiving treatment for his PTSD at the Vet Center in Houston, Texas, since June 2007. Although the evidence of record included a clinical assessment from the Vet Center, dated in November 2007, no other records from that facility had been associated with the claims file. In addition, the Board noted that the Veteran's last mental examination was more than four and a half years ago. Thus, upon remand, the RO was directed to ask the Veteran to identify the sources of all additional evaluation or treatment he had received for his PTSD since November 2007, to include the Vet Center. With any necessary authorization, the RO had to attempt to obtain all identified records. Moreover, the RO was to arrange for the Veteran to undergo a VA compensation examination in order to reassess the severity of his PTSD. Pursuant to the remand, the RO sent letters to the Veteran in October, November, and December 2012 requesting that he complete and return the enclosed authorization forms (VA Form 21-4142) so they could obtain his pertinent treatment records, including records from the Vet Center. In a VA Form 21-0820, Report of General Information, dated in January 2013, it was noted that the Veteran contacted the RO and requested a 30-day extension to submit the requested forms. He indicated that his father had recently died and that he would send the forms as quickly as possible. The evidence of record is negative for any subsequent response or submission from the Veteran. The Board observes that the duty to assist is not a one-way street. If the Veteran wants help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, the Board concludes that the RO complied with the Board's September 2012 remand directive by means of the October, November, and December 2012 VCAA assistance letters, and that the Veteran has been provided every opportunity to submit evidence and argument supporting his claim. Stegall, 11 Vet. App. at 268, 271. In addition, because the Veteran underwent a VA PTSD examination in January 2013, which was thorough in nature and adequate for the purposes of deciding this claim, the Board finds that the RO has complied with the instructions from the Board's September 2012 remand by providing the Veteran with a VA examination, as directed. Id. Therefore, the duty to assist has been satisfied, and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating his claim. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. II. Factual Background In July 2007, the Veteran filed his initial claim for service connection for PTSD. In a private medical report from the Vet Center, dated in November 2007, an examiner stated that the Veteran had presented himself in July 2007 for a PTSD evaluation. The Veteran stated that he was experiencing incapacitating anxiety, severe depressive episodes, and intense anger episodes stemming from traumatic events he experienced while participating in Operation Iraqi Freedom (OIF). He reported a history of occasional social isolation, intense frustration, night terrors, and severe sleep disruption all due to his participation in OIF. According to the Veteran, while he was in the military, he was a combat nurse and was deployed to the Middle East. He witnessed many atrocities of war and intense battle situations. The Veteran was haunted by the image of one young officer whose legs had been blown off. He reported a history of hypervigilance since departing Iraq, periodic social isolation, occasional social anxiety, intolerance to loud noises similar to the ones he heard in Iraq, intrusive thoughts, recollections about events in Iraq, and intense anger outbursts. He also noted that he had difficulty concentrating. The examiner stated that the Veteran had begun individual psychotherapy. According to the examiner, the Veteran had symptoms associated with PTSD. A VA PTSD examination was conducted in January 2008. The examiner stated that he had reviewed the Veteran's claims file. The Veteran indicated that he was a surgical nurse during service. He described seeing children, civilians, and soldiers die. At present, the Veteran reported having nightmares from his time in Iraq a couple of times per month. He noted that his wife would wake him up while he was screaming and kicking during a nightmare. The Veteran had intrusive memories of his time in Iraq. He tried to avoid talking and thinking about those incidents. The Veteran avoided watching the news and war movies. He used to be interested in bowling but since his return from Iraq, he had lost interest. The Veteran stated that he had a restricted affect when he was with his family, as well as having difficulties with intimacy with his wife. According to the Veteran, he also felt distant from friends and family. He indicated that he used to be very social but no longer wanted to talk to people. The Veteran denied problems with his memory. He reported sporadic sleep problems. At times, he slept well; other times, he would wake three to four times in the evening. The Veteran further stated that he had difficulties with irritability and his temper. He noted that he had lapses of concentration at work. He took a walk a couple times per week while he was at work. He was easily startled "every now and then" when a loud noise occurred. The Veteran denied suicidal and homicidal ideations, and auditory and visual hallucinations. He also denied significant problems with mood and appetite. According to the Veteran, he had never taken any psychiatric medications. The Veteran had a degree in nursing. He was in the Reserves and was working as a clinical research monitor. He had previously worked as a pulmonary transplant coordinator and as a nurse in the Emergency Room. The Veteran had been married to his wife for 21 years and described his relationship with her as "great." He also had good relationships with his son and step-son. He lived in a house with his wife and attended church. Upon mental status evaluation, the Veteran was appropriately dressed and was cooperative throughout the interview. He was oriented to person, place, and time. He remembered three words after immediate recall and after a short delay. The Veteran's fund of general knowledge seemed appropriate. The diagnoses were the following: (Axis I) PTSD, (Axis IV) social environment problems, and (Axis V) Global Assessment of Functioning (GAF) score of 51. The examiner stated that the Veteran presented with symptoms of PTSD related to his experiences in Iraq including nightmares and intrusive memories. He also reported avoiding talking and thinking about that time in his life, news, and war movies. He lost interest of such activities as bowling since his return from Iraq. The Veteran further felt that he had restricted affect, distance from others, and difficulties with sleeping, irritability, and concentration. He was able to maintain full-time work, as well as great relationships with his family members. His feelings of being distant from others had reduced his social interactions and affected his relationships with his wife. In a February 2008 rating action, the RO granted the Veteran's claim for service connection for PTSD. The RO assigned a 30 percent disability rating, effective from July 30, 2007, for the Veteran's service-connected PTSD. In the Veteran's August 2008 NOD, he stated that he had problems sleeping due to his PTSD. According to the Veteran, he had to take over-the-counter medications to help him fall asleep. He indicated that he also had nightmares which woke him up and then he was terrified to go back to sleep. The Veteran also noted that he had become more socially isolated and that he no longer wanted to initiate a conversation or meet a new person at work. In November 2008, the Veteran submitted a statement from his wife in support of his claim. His wife stated that since his arrival home from Iraq, he had a very difficult time falling asleep. Once he fell asleep, he had nightmares. She also indicated that his patience level had dropped considerably and it took very little to "set him off." A VA PTSD examination was conducted in January 2013. The examiner stated that he had reviewed the Veteran's claims file. The Veteran was married and had a "great" relationship with his wife. He had two sons and he described his relationship with them as "fine." The Veteran had five friends and described his general attitude towards socializing as "interested." The Veteran's free time was spent working out, fishing, and attending an annual trip with his friends during which he participated in casino gambling and skiing. He denied financial concerns or interpersonal problems related to gambling. The Veteran had completed his BSN online from Grand Canyon University in 2011. He denied problems getting along with his teachers and peers during that program. In general, he described his academic performance since his last VA examination as "good." He was currently employed full-time in the nursing education served at MD Anderson Hospital in Houston. The Veteran had retired from the military service and held one job since his last VA examination. He denied problems in getting along with co-workers or supervisors with the exception of one supervisor with whom his colleagues also had difficulty maintaining a constructive work relationship. The Veteran reported recently changing work teams and finding no interpersonal difficulties with any of the members on his new team. He denied work-related disciplinary problems since his last VA examination. According to the Veteran, he had intrusive thoughts two to three times per week and nightmares at least two to four times per month to which he responded emotionally with fear and anger, and physically with sweating. He avoided thinking or talking about his military experiences. He avoided war movies, loud noises, and any war-related media. The Veteran had reduced participation in attending football games and bowling due to distress when exposed to crowds and noise. He reported a restricted range of emotions with a distinct absence of joyful feelings. The Veteran had difficulty with sleep and averaged two to four hours of sleep per night. He was easily angered although he reported some improvement in his ability to mange his irritation and anger in recent months. The Veteran was always on guard and had difficulty relaxing in environments he knew were relatively safe. His symptoms had caused problems in social and family functioning. The Veteran denied any mental health hospitalizations since his last VA examination. Current outpatient mental health treatment included recent participation in group psychotherapy, ongoing outpatient services through psychiatry, and recent case management and psychotherapy services at his local Vet Center. He reportedly responded moderately well to these services. The Veteran stated that the skills he gained during group psychotherapy were especially useful to him and that he practiced them on a daily basis. The Veteran was currently prescribed no psychotropic medications for the symptoms outlined above. However, he had been offered ongoing psychiatric medication management services related to his sleep disturbance. Upon mental status evaluation, the Veteran was appropriately groomed and casually dressed. His manner was cooperative and his eye contact was appropriate. The Veteran's speech was unremarkable and his thought processes were logical and goal-directed. There was no evidence of hallucinations or delusions. The Veteran's mood was euthymic and his affect was mood consistent. The Veteran denied any homicidal or suicidal ideations. Activities of daily living were grossly intact. The Veteran managed his hygiene and household chores independently. He managed his medication and he was able to drive. The Veteran was oriented to place, time, and situation. With regard to concentration, he accurately completed the serial 7's task and was able to spell a 5-letter word backward and forward. Fund of basic information was generally adequate. Immediate retention was good. The Veteran demonstrated adequate understanding of a proverb. After a 3-minute delay, the Veteran was able to recall 3/3 words. The Veteran's judgment was good and his insight appeared fair. The Veteran's PTSD symptoms included anxiety, nightmares, intrusive memories, avoidance of trauma reminders, emotional numbing, blunted affect, decrease in participation in activities, insomnia, irritable outburst, and hypervigilance. The examiner noted that those symptoms had been present since his last VA examination and were of moderate intensity. Following the mental status evaluation, the diagnoses were the following: (Axis I) PTSD, (Axis III) meningoencephalitis; allergic rhinitis; low back pain; lipoma; loss of teeth; pain in shoulder joint; and hypertension, and (Axis V) GAF score of 60. When asked to choose the box that best summarized the Veteran's level of occupational and social impairment due to his PTSD, the examiner chose the box where it was noted that the Veteran had occupational and social impairment due to mild or transient symptoms with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. Given that the Veteran had successfully maintained full-time employment since his last VA examination, the examiner opined that it did not appear that the Veteran's psychiatric symptoms in any way specifically impeded him from obtaining and maintaining employment as long as he chose to do so. Indeed, it was likely beneficial for the Veteran to have had some level of employment to provided needed structure. The examiner noted that while the Veteran's PTSD symptoms had improved since his last VA examination, they remained in the moderate range of severity. He reported that the Veteran continued to use coping skills successfully. III. Analysis Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule) codified in 38 C.F.R. Part 4 (2012), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). Where there is a question as to which of two evaluations is to 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 (2012). All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3 (2012). As already alluded to, as the Veteran took issue with the initial rating assigned for his PTSD following the granting of service connection for this disability, separate ratings may be assigned for separate periods of time based on the facts found - a practice known as a "staged" rating. See Fenderson, 12 Vet. App. at 125-26. Thus, the Board must evaluate the relevant evidence since the receipt of his claim for service connection for this disability on July 30, 2007. The Veteran's service-connected PTSD is currently assigned a 30 percent evaluation in accordance with the criteria set forth in 38 C.F.R. § 4.130, Diagnostic Code 9411. This rating contemplates PTSD manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted where the disorder is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where the disorder is manifested by 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 that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; 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. The Veteran maintains that his current rating does not adequately address the symptomatology of his PTSD. He states that he has sleep problems, nightmares, anger, and an exaggerated startle response. He has submitted a statement from his wife in support of his contentions. In this regard, lay statements are considered to be competent evidence when describing symptoms of a disease or disability or an event. Symptoms, however, must be viewed in conjunction with the objective medical evidence of record. Upon a review of the rating criteria in relation to the evidence, the Board finds that the Veteran's disability picture is best characterized by the currently assigned 30 percent disability rating, and that there is a preponderance of evidence against the claim for an initial rating in excess of 30 percent for PTSD. In this case, the evidence shows that the Veteran has been oriented to person, time, and place. He experiences anxiety, irritability, sleep disturbance, nightmares, social isolation, intrusive memories, hyperstartle response, and hypervigilance. However, this evidence does not demonstrate that the Veteran's PTSD results in such impairment with reduced reliability and productivity as to warrant a 50 percent rating. The Veteran does not have a circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, or impairment of short- or long-term memory to the point that he can only remember highly learned material or forgets to complete tasks. In the Veteran's January 2008 VA examination, the Veteran denied problems with his memory. Upon mental status evaluation, he remembered three words after immediate recall and after a short delay. In the Veteran's January 2013 VA examination, immediate retention was good. In addition, the Veteran's speech was unremarkable. The Board also notes that the Veteran's PTSD does not impair his judgment or abstract thinking, or difficulty in establishing and maintaining effective work and social relationships to the degree contemplated by the 50 percent rating. Indeed, it is the criteria for the 30 percent rating that specifically refers to disturbances akin to those experience by the Veteran, such as problems with mood, anxiety, sleep impairment, etc., and the criteria for the 50 and 70 percent ratings specifically refer to manifestations beyond what the Veteran experiences. Although the Veteran is socially isolated to some degree, he has good relationships with his wife and two sons. He also has a few friends and goes fishing. In addition, the Veteran works full-time and gets along well with his co-workers and supervisors. Moreover, while he was taking online courses, he did not have any problems getting along with his teachers and peers. In the January 2013 VA examination report, the examiner stated that it did not appear that the Veteran's psychiatric symptoms in any way specifically impeded him from obtaining and maintaining employment. The Board further notes that throughout this appeal, the Veteran has consistently denied any suicidal or homicidal ideations. He has also denied any hallucinations or delusions. In regard to the Veteran's GAF scores, the Board notes that the Veteran's GAF scores actually improved from a 51 at the time of the January 2008 VA examination, to a 60 at the time of his January 2013 VA examination. As defined in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM- IV), a GAF score of 51 to 60 reflects moderate symptoms or moderate difficulty in social, occupational, or school functioning. In the January 2013 VA examination report, the examiner noted that while the Veteran's PTSD symptoms had improved since his last VA examination, they remained in the moderate range of severity. In light of the above, the Board concludes that an initial disability rating in excess of 30 percent is not warranted at any time since the initial grant of service connection. See Fenderson, 12 Vet. App. at 125-26. Accordingly, the Board concludes that there is a preponderance of evidence against the Veteran's claim for an initial evaluation in excess of 30 percent for PTSD. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply; therefore, the claim for a higher initial evaluation must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Extraschedular Rating Under 38 C.F.R § 3.321(b)(1), in exceptional cases where schedular evaluations are found to be inadequate, consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be made. The governing norm in an exceptional case is a finding that 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. See 38 C.F.R § 3.321(b)(1) (2012). Here, the rating criteria reasonably describe the Veteran's symptoms and provide for additional or more severe symptoms than currently shown by the evidence; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). As discussed above, the schedular criteria for a higher rating have not been shown. The record does not reflect that the Veteran has required any hospitalizations for his PTSD. There is also no indication in the record that the psychiatric disorder markedly interferes with his employment or daily activities, beyond what is contemplated in the rating schedule. In fact, the Veteran is currently working full-time as a nurse. In addition, in the January 2013 VA examination report, the examiner opined that it did not appear that the Veteran's psychiatric symptoms in any way specifically impeded him from obtaining and maintaining employment. Therefore, there is no indication in the record that the average industrial impairment from this disability would be in excess of that contemplated by the 30 percent rating; it is not impractical to apply the regular schedular standards. Thus, a referral for an extra-schedular rating is not warranted. ORDER Entitlement to an initial disability rating higher than 30 percent for PTSD is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs