Citation Nr: 1324632 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 11-08 211 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, and his spouse and daughter ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from April 1944 to June 1946. His awards and decorations include a Combat Infantryman Badge for his actions in the European theater during World War II. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, that granted service connection for PTSD and assigned an initial 30 percent disability rating, effective June 14, 2010. The Veteran perfected an appeal as to the assigned disability evaluation. In May 2013, the Veteran testified during a hearing at the RO before the undersigned Veterans Law Judge. A transcript of the hearing is of record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT Resolving all doubt in the Veteran's favor, since June 14, 2010, the service-connected PTSD has been manifested by moderate occupational and social impairment with reduced reliability and productivity throughout the appeal period. It has not been productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSION OF LAW Since June 10, 2010, the criteria for an initial 50 percent rating, but no higher, for PTSD, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist. As provided for by the Veterans Claims Assistance Act (VCAA), VA has a duty to notify and assist claimants in substantiating 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 and 3.326(a) (2012). In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (court) held that 38 C.F.R. 3.103(c)(2) (2009) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, this Veterans Law Judge outlined the issue on appeal and suggested that any evidence tending to show that pertinent disability had worsened in severity would be helpful in establishing the claim. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); they have not identified any prejudice in the conduct of the Board hearing. Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the 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. Here, the Veteran was sent a letter in August 2010 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The August 2010 letter provided notice as to how VA assigns an appropriate disability rating or effective date, curing any timing defect, and notice consistent with the remaining portions of the court's holding in Vazquez-Flores. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of his 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. All reasonably identified and available VA and non-VA medical records were obtained. A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence regarding the claim for an increased initial rating for PTSD on appeal. The Veteran was afforded VA examinations in August 2010 and July 2011 and the examination reports are of record. The August 2010 and July 2011 VA examination reports with the March 2012 Addendum are adequate for rating purposes as the claims file was reviewed, the examiners reviewed the pertinent history, provided clinical findings and diagnoses, and offered etiological opinions with rationales from which the Board can reach a fair determination. The records satisfy 38 C.F.R. § 3.326 (2012). 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 claims file contains the Veteran's service treatment records, as well as post-service reports of VA and non-VA treatment and examinations. 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. 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). II. Factual Background and Legal Analysis Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). In Fenderson v. West, 12 Vet. App. 119, 126 (1999), the court noted that where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" is required. Id. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's statements describing the symptoms of his service-connected PTSD are deemed competent. These statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. The September 2010 rating decision granted service connection for PTSD, and assigned an initial 30 percent rating under Diagnostic Code 9411, effective June 14. 2010. The Veteran seeks a higher initial rating. In his October 2010 notice of disagreement (NOD) and March 2011 substantive appeal, the Veteran reported having combat-related nightmares almost nightly and that he awoke in a sweat. In his NOD, for example, he stated that he woke up smelling dead rotten sheep as he had to hide out in a sheep shed for twelve days to avoid enemy soldiers while in service. He also had dreams of Normandy in which he could see and smell the blood. He also indicated that he was a loner and was best when he was by himself. During his May 2013 Board hearing the Veteran complained of sleep difficulty with worsening nightmares and he awoke talking to himself. See Board hearing transcript at pages 3 and 5. His witnesses stated that he awoke yelling and screaming and that his medication caused him to sleep all day. Id. at 5. They further indicated that he stayed home, locked the door, and feared someone was coming in. Id. at 3-4. They had to call ahead to be sure the door was opened so they could enter. Id. at 4. The Veteran's wife testified that he flew off the handle more than he used to and wanted her around, not just anyone. Id. at 6. The Veteran's wife and daughter stated that he went to family functions and church, but his daughter said he did not go elsewhere, and did not like going out in public. Id. at 8. The General Rating Formula for Mental Disorders, including Diagnostic Code 9411, that evaluates PTSD, at 38 C.F.R. § 4.130, provides the ratings for psychiatric disabilities. A 30 percent evaluation is provided for 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). 38 C.F.R. § 4.130, Diagnostic Code 9435. A 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating contemplates 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 ability 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. Also of relevance, Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), page 32). A GAF score of 51 to 60 indicates the examiner's assessment of moderate symptoms (e.g., a flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 denotes mild symptoms (e.g. depressed and mild insomnia) or some difficulty in social and occupational functioning but generally functioning pretty well, with some meaningful interpersonal relationships. Id. A GAF score of 71 to 80 denotes transient symptoms and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument) with no more than slight impairment in social and occupational functioning. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Rather, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. When it is not possible to separate the effects of a non- service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.102; Mauerhan v. Principi, 16 Vet. App. 436 (2002) (factors listed in the rating formula are examples of conditions that warrant a particular rating and are used to help differentiate between the different evaluation levels.). In August 2010, the Veteran, who was 85 years old, underwent VA examination. He did not bring his hearing aids to the interview and it was difficult for the examiner to talk with him as the Veteran could not hear. The Veteran complained of sleep difficulty and combat-related nightmares every night. He worked as truck driver and stopped working because of his age. The Veteran had a good relationship with his third wife, to whom he was married for 24 years, and his two sons. He had friends everywhere, and liked to mow and garden and cut down hedge rows. There was no history of assaultiveness and no history of suicide attempts. The Veteran felt that his combat-related stressful situations were happening all over again. His only real complaint was nightmares and waking up talking to himself. On examination, there was no impairment of thought process but there was impaired communication in that the Veteran had significant hearing loss. The hearing loss and eyesight affected his social functioning. There were no delusions or hallucinations and no suicidal or homicidal thoughts. He was able to maintain minimal personal hygiene and other basic activities of daily living. He was oriented to person, place, and time. The Veteran had slight, short term memory impairment, described as mild. There was no obsessive or ritualistic behavior and there were no panic attacks. He had normal speech and occasionally felt depressed, described as mild depression, that did not affect his going to church or visiting with others. The Veteran denied having anxiety and there was no impaired impulse control. He had nightly and significant sleep impairment. The Axis I diagnosis was mild PTSD and a GAF score of 75 was assigned. The Veteran indicated that the PTSD only affected his sleep and he had nightmares, but the examiner reiterated that the Veteran was hard of hearing. The Veteran indicated that he told the examiner more about World War II than he ever told anybody. The VA examiner reported that there were PTSD signs and symtoms that were transient or mild, that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner also noted that PTSD symtoms were not severe enough to interfere with occupational and social functioning, that the Veteran only had a mild condition, and that the prognosis was poor due to his age. In July 2011, the Veteran underwent another VA examination. At that time, his health was worsening. He stopped driving a truck in 1987 and stopped farming for himself in 2000 when his eyesight worsened. The Veteran had been married for 23 years to his third wife and he said that went well because she was outspoken and made him apologize when he got too cranky. The Veteran got along with his two sons who called weekly or every few months. His younger brother visited almost daily, and several other family members visited weekly to play dominos on Sundays at his home, although he was no longer able to play. The Veteran avoided crowds and large social events, except for going to church and joining his family on several holidays. He had one friend from childhood. He was close to his family, had a good friend, and spent most of his time at home watching television and dozing. He had nightmares several times a week. On examination, the Veteran was neatly groomed and appropriately dressed and was noted to be able to maintain minimum personal hygiene. His psychomotor activity was restless, lethargic, and tense. He used a walker and dark glasses due to light sensitivity, and refused to wear his hearing aid due to it sounding too loud. The Veteran's speech was slow and clear, and his attitude was cooperative, friendly, and attentive. His affect was appropriate and constricted, his mood was anxious and agitated, and he was easily distracted with a short attention span (attention disturbance). He was oriented to person and place, but not to time. He did not know the day of the week, month, or year. The Veteran's thought process was unremarkable and it was noted that he did not like crowds. Further, the Veteran had no delusions or hallucinations or homicidal or suicidal thoughts. He understood the outcome of his behavior and that he had a problem. There was poor sleep. There was no inappropriate behavior and no obsessive/ritualistic behavior. The Veteran had panic attacks monthly that were mild and lasted minutes that resulted in his avoiding crowds or staying outside in thunderstorms. He had good impulse control with no episodes of violence. Remote and immediate memory was mildly impaired and his recent memory was moderately impaired. The VA examiner reported that the Veteran had a problem with activities of daily living that prevented him from participating in other recreational activities and caused a severe problem doing household chores and engaging in sports/exercise. However, there was no interference with shopping, or completing other activities of daily living. The Veteran's mild to moderate PTSD symtoms occurred more than weekly and included persistent re-experiencing of traumatic events by recurrent and intrusive thoughts, images, or perceptions and physiological reactivity on exposure to internal or external cues. There was persistent avoidance of stimuli associated with trauma and numbing of general responsiveness manifested by avoidance of feelings and activities that were associated with the trauma or aroused recollections. There was markedly diminished interest or participation in activities and feelings of detachment from others. He had sleep and concentration difficulty, and irritability or outbursts of anger. His nightmares worsened after he stopped working ten years earlier. The VA examiner found that psychometric test results suggested mild to moderate PTSD with secondary depression and loss of concentration. Moderately severe PTSD symtoms based on psychometric data was reported. As noted, the Veteran retired in 2000 due to age eligibility or duration of work and physical problems, including poor vision, balance, and seizures. The Axis I diagnoses were PTSD and depressive disorder, not otherwise specified (NOS), and a cognitive disorder, NOS. A GAF score of 60 was assigned. The VA examiner commented that the Veteran experienced feelings of worthlessness, irritability, panic, insomnia, nightmares, and loss of concentration, and that he was retired, with few friends/activities, and had conflicts with family. The examiner opined that the Veteran's cognitive disorder NOS was largely secondary to and could not be separated from his PTSD. The examiner reported that there was occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks due to PTSD signs and symtoms but, with generally satisfactory functioning. Pertinent symtoms included irritability, panic, insomnia, nightmares, loss of energy/concentration, retirement, few friends/activities, and conflicts with family. According to a February 2012 PTSD examination report completed by J.C.W., Ed.D., a private psychologist, the Veteran's current diagnoses were PTSD and a depressive disorder, NOS. Dr. W. noted his review of a January 12, 2012 report from VA (that may be a reference to the January 2012 supplemental statement of the case) and the Veteran's service records. The Veteran's history of being terrified while missing in action during World War II was noted. The Veteran thought daily of his fears of dying while in combat and had daily combat-related dreams. He experienced recurrent recollections of combat-related events and tried to avoid such thoughts and feelings and felt detached or estranged from others. According to Dr. W., the Veteran's symtoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impaired short and long term memory, flattened affect, impaired abstract thinking, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting, intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, and disorientation to time or place. Dr. W. assigned a GAF score of 60. This provider then stated that it was not possible to differentiate what symtoms were attributable to each diagnosis and that the Veteran's depression was secondary to his PTSD. The psychologist also reported that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood disorder. Dr. W. indicated that it was not possible to differentiate what portion of the occupational and social impairment was caused by each mental disorder, as the Veteran's depression appeared secondary to his PTSD but may be co morbid. In a March 2012 Addendum, the recent VA examiner reviewed his July 2011 examination report, and Dr. W.'s February 2012 report. The VA examiner noted that his report indicated that the overall pattern suggested mild to moderate PTSD with secondary depression and loss of concentration, with moderately severe PTSD symtoms based on psychometric data. A GAF score of 60 was assigned that corresponded to a moderate level of PTSD severity. Both he and Dr. W. reported a GAF score of 60 that accurately reflected the Veteran's ability to function within his environment as reflected by the phrase "intermittent periods of inability to perform." Despite the increased nightmares and irritability as his mobility declined with advanced age, the Veteran was able to interact appropriately with the support of his spouse. After reviewing the record and the relevant rating criteria, it is concluded that a 50 percent rating, but no more, is warranted for the Veteran's PTSD since he filed his initial service connection claim in June 2010. The August 2010 VA examiner indicated that the Veteran had mild memory loss, nightly sleep disturbance, and mild depression, and assigned a GAF score of 75 commensurate with transient symtoms. In July 2011, a VA examiner reported the Veteran's irritability, panic, insomnia, nightmares, loss of energy/concentration, few friends/activities, and conflicts with family and assigned a GAF score of 60, commensurate with moderately severe disability. Then, in February 2012, Dr. W., the private psychologist, described the Veteran's symtoms of depressed mood, anxiety, suspiciousness, sleep difficulty, flattened affect, impaired memory and abstract thinking, disturbed mood and motivation, difficulty adapting to stressful circumstances, disorientation to time and place, and intermittent inability to perform activities of daily living including maintaining of minimum personal hygiene and but also assigned a GAF score of 60. In his March 2012 Addendum, the July 2011 VA examiner noted that both he and Dr. W. assigned GAF scores of 60, essentially commensurate with moderate impairment, that accurately reflected the Veteran's ability to function within his current environment as reflected by the phrase "intermittent periods of inability to perform". The examiner acknowledged the Veteran's increased nightmares and irritability although he found that the Veteran was able to interact appropriately with his wife's support. Significantly, in May 2013, the Veteran and his wife and daughter provided credible testimony to the effect that he had worsening nightmares and irritability, feared being alone, and was socially isolated. As noted above, a global assessment of functioning score is a scale reflecting a patient's psychological, social, and occupational functioning on a hypothetical continuum of mental health and illness. Carpenter, 8 Vet. App. at 242. It is wholly appropriate for adjudicators to look to these scores in evaluating psychiatric disability since, as noted above, the evaluation of such disabilities involves the application of a rating schedule that in turn is based on average impairment of earning capacity. The February 2012 private examination report from Dr. W. reflects symptoms consistent with a 50 percent evaluation under Diagnostic Code 9411. The other medical evidence, including the August 2010 and July 2011 VA examination reports, further demonstrates that the Veteran reported irritability, memory loss, sleep difficulty and combat-related nightmares, intrusive thoughts, social isolation, and panic attacks monthly In view of the foregoing, the Board concludes that the evidence is at least in relative equipoise as to whether the disability picture more nearly approximates the criteria for a 50 percent evaluation. See 38 C.F.R. § 4.7 However, the record does not show persistent symptoms that equal or more nearly approximate the criteria for a rating in excess of 50 percent. Indeed, symptoms such as spatial disorientation, near-continuous panic, or other symptoms set out for the 70 percent rating are not shown. Although an intermittent ability to perform activities of daily living including maintenance of minimum personal hygiene was noted by Dr. W. in February 2012, such was not noted by the 2010 and 2011 VA examiners. In fact, the July 2011 VA examiner described the Veteran as neatly and appropriately dressed. While Dr. W. reported that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood disorder that might imply that a higher 70 percent rating might be for consideration, the psychologist did not report that the Veteran had panic attacks that occurred more than once a week, illogical speech, obsessional rituals, or presented a danger of hurting himself or others. Additionally, while the August 2010 VA examiner described the Veteran as oriented to person, time, and place, the July 2011 VA examiner said he was not oriented to time, and Dr. W. reported that the Veteran had impaired abstract thinking. But neither examiner nor Dr. W. reported evidence of psychotic thought, grossly inappropriate behavior or persistent delusions or hallucinations. Furthermore, although the Veteran reported some irritability in his marriage on his part, he said that he had a good relationship with his wife, to whom he was married for 27 years, and his two sons. The Board acknowledges that the absence of specific symptoms noted in the criteria for the next-higher 70 percent rating are not fatal to the claim. The primary consideration is the overall level of impairment, as due to any symptoms. Here, however, the level of impairment is not commensurate with deficiencies in most areas and an inability to establish and maintain effective relationships. As such, a rating in excess of 50 percent is not warranted at any time since the Veteran filed his initial claim in June 2010. In sum, resolving reasonable doubt in the Veteran's favor, an initial 50 percent rating, but no higher, is granted for PTSD, but the preponderance of the objective medical and other credible evidence of record is against a rating in excess of 50 percent. The benefit of the doubt has been resolved in the Veteran's favor to this limited extent. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, supra. The Board has also considered whether the Veteran's PTSD disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2012). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. at 182. Here the Board has considered Mittleider and attributed all potentially service-connected symtoms to his service-connected PTSD disability before considering if the Veteran is entitled to an extra-schedular rating. If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The manifestations of the Veteran's disability include memory loss, irritability, social isolation, anxiety and depressed mood. The rating schedule contemplates these symptoms. Diagnostic Code 9411. The rating schedule is meant to compensate for average impairment in earning capacity and for considerable time lost from work commensurate with the percentage evaluations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration. Id.; see also Thun v. Peake, 22 Vet. App. at 111. 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). Here, the Veteran repeatedly told VA examiners, most recently in 2011, that he retired in 2000 from his work as a truck driver and farmer due to age and vision problems. Thus, any further consideration of the Veteran's claim under Rice is not warranted at this time. Further, in view of the holding in Fenderson, and, based upon the record, the Board finds that at no time since the Veteran filed his most recent claim for service connection has the disability on appeal been more disabling than as currently rated under the present decision of the Board. ORDER An initial 50 percent rating, but no higher, for PTSD is granted from June 14, 2010, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs