Citation Nr: 1324232 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 06-13 605 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial increased rating for posttraumatic stress disorder (PTSD), evaluated as 30 percent disabling, prior to August 26, 2010. 2. Entitlement to an initial increased rating for PTSD, evaluated as 50 percent disabling from August 26, 2010 to February 14, 2011. 3. Entitlement to an initial increased rating for PTSD, evaluated as 70 percent since February 14, 2011. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. Jivens-McRae, Counsel INTRODUCTION The Veteran served on active duty from June 1966 to June 1969. He served in the Republic of Vietnam and was awarded the Air Medal and the Purple Heart. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2005 rating decision of the St. Louis, Missouri, Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for PTSD and assigned a 30 percent disability rating, effective December 2004. In March 2009 and November 2012, the Board remanded the instant claims for further development. That development has been accomplished and the claims file was returned to the Board for final appellate consideration. FINDINGS OF FACT 1. Prior to April 2009, the Veteran's PTSD was productive of no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; however, occupational and social impairment with reduced reliability and productivity due to symptoms as flattened affect; panic attacks more than once a week; difficulty understanding complex commands; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships has not been shown. 2. Since April 2009, the Veteran's PTSD is productive of no more than occupational and social impairment in family relations, judgment, thinking, or mood; however, total occupational and social impairment due to such symptoms as persistent delusions and hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; memory loss for names of close relatives or own name has not been shown. CONCLUSIONS OF LAW 1. The initial criteria in excess of 30 percent for PTSD have not been met prior to April 2009. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). 2. The initial criteria in excess of 70 percent, and no more, for PTSD have been met since April 2009. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Assist and Notify Before addressing the merits of the claim, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). The notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet.App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The Board notes that where service connection has been granted and an initial rating and effective date have been assigned, the claim of service connection has been more than substantiated, as it has been proven. As such, 38 U.S.C.A. § 5103(a) notice is no longer required since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, any defect as to 38 U.S.C.A. § 5103(a) notice is nonprejudicial. See Dunlap v. Nicholson, 21 Vet.App. 112 (2007); Goodwin v. Peake, 22 Vet.App. 128 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseski v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet.App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet.App. 112 (2007). None is found by the Board. Next, VA has a duty to assist a veteran in the development of the claims. This duty includes assisting him or her in the procurement of service treatment records, private treatment records, and other pertinent VA treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The RO associated the Veteran's service treatment records, Social Security disability records, and VA treatment records with the claims file. No outstanding evidence has been identified. The Veteran was afforded VA examinations in June 2005 and August 2010. The Board finds the VA examination reports were thorough and adequate upon which to base a decision with regard to the Veteran's PTSD claim. The VA examiner personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information necessary to evaluate his disability under the applicable rating criteria. Further, the Veteran was provided an opportunity to set forth his contentions at a hearing before the Board. He declined. The Board concludes that all the available records and medical evidence have been obtained in order to make an adequate determination as to this claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist 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). Initial Increased Rating-PTSD The Veteran asserts that his PTSD is more severe than currently rated. He claimed that he continued to be depressed, have short and long term memory loss, and is unable to get along with people. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet.App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet.App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). In determining the level of impairment, the disability must be considered in the context of the whole recorded history. 38 C.F.R. §§ 4.2, 4.41 (2012). An evaluation of the level of disability present also includes consideration of the functional impairment of the appellant's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2012). When the appeal arises from an initial rating, as in this case, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet.App. 119 (1999). Staged ratings are also appropriate in increased- rating claims in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet.App. 505 (2007). When an already established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet.App. 55 (1994). By rating decision of July 2005, service connection for PTSD was granted. PTSD was awarded a 30 percent rating, effective December 2004. By rating decision of August 2012, the 30 percent rating was increased to 50 percent, effective August 2010. A 70 percent rating was assigned, effective February 2011. A 70 percent rating has been effective since that date. The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, for PTSD. Under the General Rating Formula for Mental Disorders, Diagnostic Code 9411, 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, is rated 100 percent disabling. 38 C.F.R. § 4.130. 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 is to be rated 70 percent disabling. 38 C.F.R. § 4.130. 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 is to be rated 50 percent disabling. 38 C.F.R. § 4.130. Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) is to be evaluated as 30 percent disabling. 38 C.F.R. § 4.130. Occupational and social impairment due to mild or transient symptoms which decreases work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by continuous medication, is to be evaluated as 10 percent disabling. 38 C.F.R. § 4.130. The Board also notes that, under 38 C.F.R. § 4.130, the nomenclature employed in this portion of the rating schedule is based upon the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition, of the American Psychiatric Association (DSM-IV). As indicated in Carpenter v. Brown, 8 Vet.App. 240, 242 (1995), the GAF is a scale reflecting the psychological, social and occupational functioning on a hypothetical continuum of mental health-illness and a 61-70 score indicates some mild symptoms (e.g . depressed mood and mild insomnia) or some difficulty in social occupational, or school functioning (e.g., occasional truancy, or within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A 51-60 score indicates moderate symptoms, e.g., flattened affect, circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational or school functioning; e.g., having few friends or having conflicts with peers or co-workers. A GAF score of 41 to 50 reflects a serious level of impairment, e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting or serious impairment in social, occupational or school functioning, e.g., no friends, unable to keep a job. A GAF score of 31 to 40 reflects some impairment in reality testing or communication, e.g., speech is illogical at times, obscure or irrelevant, or major impairment in several areas such as work, school, family relations, judgment, thinking or mood, e.g., depressed man avoids friends, neglects family, and is unable to work. See 38 C.F.R. § 4.130. After scrutinizing the evidence - which includes VA outpatient treatment records, and VA examination reports-the Board finds that the totality of the evidence fails to support the assignment of a rating greater than 30 percent for the Veteran's PTSD prior to April 2009. Since April 2009, the Veteran's PTSD warrants a 70 percent rating and no more. The Veteran underwent a VA psychiatric examination in June 2005. He complained of symptoms of depression, occasional nightmares, increased temper, increased violent behavior when angry, irritability, nervousness, and anxiety. He related that he has been married for 39 years and he describe their marriage as fine and that they enjoyed each other's company. He has a 29 year old daughter with whom he has an "ok" relationship. He continued to keep in touch with friends from high school; however, he did not socialize much with people. He socialized with others a couple of times a year. He retired in 2003, and spends his time fixing on his in-laws, his daughter's and his own home. He reported the death of his father on his birthday one year earlier. He enjoys hunting and fishing but has not had time to engage in these activities recently. Mental status examination revealed the Veteran to be alert, oriented times 3, and cooperative. He maintained good eye contact and his speech was normal and clear. His thought process was goal directed. Thought content was without visual and auditory hallucinations, and without suicidal and homicidal ideation. He exhibited no illogical behavior. He maintained personal hygiene and other activities of basic living. He had no memory impairment or obsessional or ritualistic behavior. He expressed no history of panic attacks. He had "ok" impulse control. He was depressed and had anxious mood. He had sleep impairment and stated he was mentally slower. He had difficulty concentrating and thinking. He indicated he was easily frustrated. The pertinent diagnosis was PTSD with depressed mood. His global assessment of functioning (GAF) was 62. VA outpatient treatment records from February 2006 to March 2010 were reviewed and associated with the claims folder. In February 2006, the Veteran was seen with his wife in the mental hygiene clinic. Both expressed that his PTSD had become worse. His wife stated that he had not been seen in approximately 2 years. She related that the death of the Veteran's parents had been big stressors for him. The Veteran expressed difficulty sleeping, more nightmares, and increased anger with violent verbal outbursts. His temper was triggered by smaller stressors and he reported his motivation was very low and he did not care about anything. He had suicidal ideation but denied current intent. He denied homicidal ideation. Mental status examination revealed restricted affect, eye contact avoidance, and slowed speech. He described his mood as anxious. He reported auditory and visual phenomena. He related irritability. His insight was fair. His judgment was such that he was seeking treatment. The pertinent diagnosis was PTSD and major depressive disorder (MDD) with psychotic disorder. He was prescribed 3 medications (Zoloft, Trazodone, and Seroquel) and was instructed to return in 1 week. The Veteran returned to the VA mental hygiene clinic one week later indicating that he was now able to sleep, not having nightmares, significantly less anxious, had a better mood, and his motivation was returning. He indicated that he took the Trazodone and Zoloft, but did not take the Seroquel, due to a fear of being on too many medications and metabolic issues. He continued to relate that he still saw movements/things out of the corner of his eye, but when he turned to look, nothing was there. He stated he had increased anxiety when this occurred, up to 3 to 4 times a day, until it turned out not to be anything there. However, he related that he had decreased anxiety and he had no more suicidal ideation. Mental status examination revealed affect was still constricted but he rated his mood as good. Speech was less slowed. His thoughts were goal-directed. There was no suicidal or homicidal ideation. His temper and irritability was lessened. The examiner stated that his improvement in 1 week was quite dramatic and possibly better than expected. The examiner attributed this to relief from chronic lack of sleep and nightmares. The Veteran was encouraged to take his medication and return to the clinic in 3 weeks. GAF was 60. In March 2006, the Veteran returned to the VA mental hygiene clinic. At this time, he reported that he was doing better and was no longer having dreams and rages. He stated he slept well if he took the Trazodone, but indicated that he only took it if he felt he needed it. His mood was improved to an 8/10. He had no suicidal or homicidal ideation and saw no more "spooks" out the corner of his eye. His affect was constricted and his speech was within normal limits. At the time of the examination, he stated that he was cleaning the brush on his land, and had recently taken a trip with some friends that he found to be relaxing. He reported that he only took the Zoloft occasionally. The assessment was MDD, PTSD, partial remission. He was encouraged to stay compliant with the Zoloft and told he could take the Trazodone as needed. His GAF was 55. The Veteran was seen in April 2009 in the VA mental hygiene clinic. He stated that he had not been seen since March 2006. He related that he ran out of his medication a few months earlier, but he did not know how helpful they were. He stated that he continued to have anger and felt rage building up inside of him. He recently threw pool balls when he was out with some friends. He avoided talking about his experiences as a helicopter pilot in Vietnam. He complained of night sweats and bad dreams approximately twice a week. He related that a few months prior to his examination, he grabbed his wife by the throat in his sleep. He endorsed depressed mood, not enjoying activities, hopelessness, and suicidal thoughts. He denied suicidal intent or plan. He stated he drank 4 to 5 beers a day and drank a fifth of liquor over the week. The assessment was PTSD, major depression, and alcohol abuse. The Veteran indicated that he would restart Trazodone for sleeping and the examiner encouraged him to start Sertraline for depression. The Veteran was seen by VA in May 2009. He complained of nightmares several times a week with an inability to fall back to sleep. He experienced frequent sleep problems. He expressed difficulty with anger and trouble controlling aggressive behavior. He had night sweats and thrashed around in his sleep. He avoided discussing traumatic events with others. He avoided crowds. He kept a gun with him nearly all the time. He detached himself from others. Mental status examination revealed the Veteran to be casually dressed and well-groomed. He appeared mildly depressed. He denied suicidal and homicidal ideation. His thoughts appeared clear and his affect was appropriate. He displayed good eye contact. His speech was organized and goal-directed. There was no evidence of perceptual distortion noted. The diagnostic impression was PTSD and MDD. In June 2009, the Veteran was seen for a follow-up for his PTSD. He reported feelings of tension. He also reported that his anxiety and feelings of guilt had contributed to continued use of alcohol. In September 2009, he was mildly tense during his session. He indicated he felt no change in his symptoms. He continued to have lots of nightmares involving fear of harm from others. He also reported that others identified him as angry and intimidating, although he did not perceive those feelings. In November 2009, he appeared mildly tense during the session. He reported trying deep breathing techniques. He reported mild improvement in avoiding verbal aggression. He reported working on projects at home to distract him from tension. He continued to have trouble sleeping, waking several times per night. In March 2010, the Veteran indicated a slight increase in alcohol use, drinking 5 or 6 drinks per day. He reported not having many activities. He reported some depressed mood and anhedonia resulting in him staying away from home more. He reported his temper was increasing. The Veteran underwent a VA examination in August 2010. Since his last VA examination, he indicated that he received individual psychiatric and psychological treatment with only fair benefit. The Veteran's employment status had not changed since his last examination as he retired in 2003. He reported that he was married, had 1 daughter, and 2 grandchildren. He had seen his daughter and grandchildren on only 2 occasions in the past year. He had no telephone contact with them, although his wife maintained regular contact with them. As for social functioning, he had few friends and spent most of his time with his wife. His alcohol consumption had increased as it was reported that he was drinking 8 to 10 beers plus a couple of shots of whiskey on a daily basis for the past 6 to 9 months. He reported that the alcohol helped him to sleep. Since his last examination, he had an increase with his lack of impulse control. He had angry outbursts, road rage, carried a concealed gun much of the time, and engaged in a physical fight with a stranger on the airplane who shoved his wife. He denied suicide attempt since his last evaluation. He also stated he did not experience active suicidal ideation, but had thoughts that death would be "easier than living." Mental status examination revealed the Veteran to be alert, oriented times 3, and cooperative. He maintained good eye contact. His speech was normal and clear. He was cooperative with the evaluation. His thought process was goal-directed and his thought content was without audio and visual hallucinations and without suicidal or homicidal ideation. He presented with a "fine" mood and a somewhat blunted affect. He exhibited short term memory problems, having problems remembering names, directions, and well learned destinations. He stated his wife did most of the driving. He had no obsessive or ritualistic behavior. The pertinent diagnosis was PTSD. His GAF was 50. VA outpatient treatment records from February 2011 to July 2011 were reviewed and associated with the claims folder. In February 2011, the Veteran was seen complaining of his inability to go into crowded places, having to watch his back at all times, and reexperiencing nightmares of war. He was casually dressed and very anxious. He was hypervigilant and was noticed to be sitting with his back to the wall watching the front door. His speech was coherent, relevant, and goal-directed. His mood was irritable. His affect was appropriate. He denied current homicidal or suicidal thoughts or plans. There was no evidence of hallucinations or delusions. In March 2011, the Veteran appeared tense during his follow-up PTSD session. He expressed difficulty with hypervigilance and indicated he sat with his back to the wall when around others. Upon direct questioning, he denied homicidal and suicidal ideation. He was seen later that month and it was noted that he was hypervigilant, sitting with his back to the wall. Mental status examination revealed the Veteran to be casually dressed. He was very anxious. His speech was coherent, relevant, and goal-directed. His mood was irritable and very depressed. His affect was appropriate. He related having very distressing thoughts and dreams of traumatic events. He denied suicidal or homicidal ideation. He had no evidence of hallucinations or delusions. In April 2011, the Veteran discussed having an incident during the week of his individual therapy that included yelling and becoming intimidating. He also reported experiencing difficulty with marital conflict. In July 2011, the Veteran was seen in individual therapy. He indicated that he kept to himself and occupied himself with small projects to keep himself busy. He reported that as long as he kept himself busy, he had less distressing memories of events from the war. He used Trazodone rarely. He reported his mood had improved. He reported periods of anger, but that he was not a violent man. He dealt with his anger by isolating himself. He admitted he refused to go to a family gathering with his daughter to Florida. He remained hypervigilant. The examiner suggested that he consider attending group therapy in 2012. Prior to April 2009 Prior to April 2009, the Veteran's PTSD was productive of no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; with symptoms of depressed mood, anxiety, suspiciousness, and chronic sleep impairment, more nearly approximating a 30 percent rating. The Veteran's PTSD had not, for the period prior to April 2009, exhibited occupational and social impairment with reduced reliability and productivity due to symptoms as flattened affect; panic attacks more than once a week; difficulty understanding complex commands; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships . The presence or lack of presence of these symptoms is not outcome determinative. However, based on the totality of the record, the assignment of a higher (50 percent) rating during this period is not warranted. During this period, the Veteran underwent one VA examination in June 2005. He also was seen in the mental hygiene clinic on an outpatient basis. It was noted during this time period that he had complaints of depression, irritability, nervousness, increased temper, and anxiety. He had a good marital relationship of over 29 years, and an "ok" relationship with his adult daughter. He was retired from his employment and received Social Security for disability not related to his PTSD. He was mentally slower, and easily frustrated. He had no history of panic attacks, no obsessional or ritualistic behavior, and no problems with personal hygiene. His main problem appeared to be his chronic sleep impairment. Although he was noted on outpatient treatment to have auditory and visual phenomena sightings, along with some suicidal ideation, these symptoms substantially decreased in one week after being medicated with Trazodone and sustaining better sleep. The examiner at that time encouraged him to stay compliant with his medication, although the Veteran reported he had a fear of taking too many medications due to metabolic issues. His GAF for his PTSD at that time was scored in the range of 55 to 62, which is indicative of mild to moderate symptomatology throughout the rating period. Since April 2009 However, during the period since the April 2009, the Board finds that the symptoms of the Veteran's PTSD were productive of findings exhibiting occupational and social impairment in family relations, judgment, thinking, or mood. Again, in not entrenching itself in the list of enumerated symptoms, the Board finds that the totality of the evidence support the assignment of a 70 percent rating for PTSD during this period. As discussed, when the Veteran was seen in April 2009, he had not been to the mental hygiene clinic in 3 years. At that time, he went to the clinic because he had run out of his medication, although he expressed that he did not know how helpful the medication was. He related he had begun to have night sweats, and he endorsed depressed mood, hopelessness and suicidal thoughts. He was restarted on Trazodone and begun on another medication (Sertraline) for depression. During this period, the Veteran's sleep disturbance increased, with nightmares several times a week. He became more angry, intimidating, and increased alcohol use in order to sleep. It was noted during an August 2010 VA examination, that he had engaged in a physical fight with a stranger, had angry outbursts, road rage, and carried a concealed gun much of the time. He became more hypervigilant, and began to become increasingly isolated. Although he stated that he had begun to only have short term memory difficulties, he stated that he had problems remembering names, directions, and well learned destinations. His wife did most of the driving. He and his wife had begun to experience marital conflict. He reported that in addition to isolating himself from friends, he refused to go to a family gathering with his daughter to Florida. Based on these findings, the Veteran warrants a 70 percent rating, and no more, for the period since April 2009. However, at no time during the appeals period, has the Veteran experienced symptomatology indicative of total occupational and social impairment due to such symptoms such 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; or memory loss for names of close relatives, own occupation, or name, symptoms that are indicative of a total rating. The Veteran has continued to be described as casually dressed and well-groomed. Although depressed, anxious, and sometimes expressing suicidal ideation, his symptomatology has never risen to the level of gross impairment of thought processes or communication. He generally had been noted to have good eye contact, and his thought process has been described as goal-directed. Although he had difficulty with hypervigilance, isolation, anger and impulsivity, and was known to carry a concealed weapon at most times, he did not have persistent delusions or hallucinations, and there was no evidence of persistent danger in hurting himself or others. The Board recognizes that the failure to meet the enumerated criteria of 38 C.F.R. § 4.130 does not preclude the Veteran from receiving a higher disability rating. However, as discussed, the totality of the evidence does not rise to the level of a 100 percent rating. The Board has considered the Veteran's statements that his PTSD is worse. He asserted, in essence, that he warranted an increased rating for his PTSD disability. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet.App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet.App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet.App. 67, 74 (1997); Layno v. Brown, 6 Vet.App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet.App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet.App. at 470. However, the Veteran has not been shown to possess the competence to identify a specific level of disability of this disorder according to the appropriate diagnostic code. Such competent evidence-concerning the nature and extent of the Veteran's PTSD has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which the Veteran's PTSD disability is evaluated. The Board has also considered whether referral for an extraschedular evaluation is warranted. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet.App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet.App. 242 (2008). Under the provisions of 38 C.F.R. § 3.321(b)(1) (2011), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." Id. The Court clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet.App. 111 (2008). A determination of whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology first must be made by the RO or Board. If the rating criteria are inadequate, the RO or Board must proceed to determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. In this case, there has been no showing that the Veteran's disability picture could not be contemplated adequately by the applicable schedular rating criteria discussed above. The evaluation of the Veteran's PTSD was applied to the applicable rating criteria and case law. Although the applicable criteria provide for higher ratings, the Board fully explained why the higher ratings were not warranted throughout. Given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's PTSD includes exceptional factors. Referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet.App. at 11 ; see also Bagwell v. Brown, 9 Vet.App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet.App. 88, 96 (1996); Shipwash v. Brown, 8 Vet.App. 218, 227 (1995). Finally, in Rice v. Shinseki, 22 Vet.App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. During the appellate period, a TDIU was granted in a rating decision of September 2011. The TDIU became effective February 2010. It is important to note that the Veteran retired from his employment in 2003, prior to this appeals period. Moreover, the Veteran is in receipt of Social Security disability benefits due to his back and his diabetes mellitus, type II. The record does not show, and the Veteran has not indicated, that he is unable to work as a result of his PTSD. As he has already been granted a TDIU and he did not indicate that he was unable to work at any time during the appellate period because of his PTSD, the issue of a TDIU for any time during the appellate period is not before the Board at this time. ORDER Entitlement to an initial increased rating in excess of 30 percent prior to April 2009 is denied. Entitlement to an initial increased rating of 70 percent, and no more, since April 2009, is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs