Citation Nr: 1329142 Decision Date: 09/11/13 Archive Date: 09/17/13 DOCKET NO. 08-37 410 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to an evaluation in excess of 50 percent disabling for posttraumatic stress disorder (PTSD) with depressive disorder, not otherwise specified. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and C.B. ATTORNEY FOR THE BOARD J. Juliano, Counsel INTRODUCTION The Veteran served on active duty from July 1966 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) regional office (RO) located in Denver, Colorado. In February 2013, the Veteran testified before the undersigned Veterans Law Judge at a videoconference Board hearing at the RO located in Denver, Colorado. A transcript of the proceeding has been associated with the claims file. In March 2013, the Board remanded the Veteran's claim for further development. Such development has been completed and associated with the claims file, and this matter is returned to the Board for further review. FINDING OF FACT The Veteran's service-connected PTSD with depressive disorder, not otherwise specified, is manifested by occupational and social impairment with reduced reliability and productivity due to symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment with nightmares, mild memory loss, restricted affect, frequent panic attacks, passive suicidal thoughts and disturbances of mood or motivation. CONCLUSION OF LAW The criteria for an evaluation in excess of 50 percent disabling for PTSD with depressive disorder, not otherwise specified, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) With regard to the Veteran's claim for an increased rating for PTSD with depressive disorder, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Under the Veterans Claims Assistance Act of 2000 (VCAA), when VA receives a complete or substantially complete application for benefits, it is generally required to "notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided . . . that is necessary to substantiate the claim." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). As part of that notice, VA must "indicate which portion of that information and evidence, if any, is to be provided by the claimant and which portion, if any, the Secretary . . will attempt to obtain on behalf of the claimant." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board finds that an August 2009 VCAA letter fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1) (2012). The August 2009 VCAA letter informed the Veteran of what information or evidence was needed to support his claim, what types of evidence the Veteran was responsible for obtaining and submitting to VA, and which evidence VA would obtain. The letter also explained how VA assigns disability ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board also concludes that VA's duty to assist has been satisfied. The Veteran's VA and private treatment records are all in the claims file. Pursuant to the Board's March 2013 remand directive, the Veteran's VA treatment records dated since January 2010 have been associated with the record. Therefore, the Board finds that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran has at no time referenced outstanding records that he wanted VA to obtain. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of a veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The Veteran has been provided with VA examinations relating to his PTSD with depressive disorder, not otherwise specified, in September 2008 (shortly prior to the filing of his claim), November 2009, April 2012, and April 2013. There is no evidence indicating that there has been a material change in the severity of the Veteran's service-connected PTSD with depressive disorder since he was last examined. See 38 C.F.R. § 3.327(a) (2012). In fact, the last April 2013 VA examination was provided pursuant to the March 2013 Board remand based on the Veteran's alleged worsening of symptoms, and the Board finds that the examination report is adequate to address the severity of the Veteran's condition and, therefore, there has been substantial compliance with the Board's remand directive. See Stegall v. West, 11 Vet. App. 268 (1998). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. The Board finds the above VA examination reports to be thorough, complete, and adequate upon which to base a decision with regard to this claim. The VA examiners had an opportunity to personally interview and examine the Veteran, and their reports provide the information necessary to evaluate the Veteran's disability under the applicable rating criteria. As such, the Board finds the examination reports to be adequate upon which to base a decision. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of a veteran. 38 C.F.R. § 4.3 (2012). Where service connection has already been established and an increase in the disability rating is in issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability in issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). The regulations establish a general rating formula for mental disabilities. 38 C.F.R. § 4.130 (2012). Ratings are assigned according to the manifestation of particular symptoms. Notably, the term "such as" in 38 C.F.R. § 4.130 precedes lists of symptoms that are not exhaustive, but rather serve as examples of the type and degree of symptoms and their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F. R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The Veteran's PTSD is evaluated under Diagnostic Code 9411. See 38 C.F.R. § 4.130. Diagnostic Code 9411 provides that the criteria for a 50 percent rating are as follows: 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. The criteria for a 70 percent rating are as follows: 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. Within the DSM-IV, Global Assessment 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). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school function (such as few friends, conflicts with peers or coworkers). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasional failure to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. 38 C.F.R. § 4.130 (incorporating by reference VA's adoption of the DSM-IV for rating purposes). The Veteran's PTSD is currently assigned a disability rating of 50 percent under Diagnostic Code 9411. The Veteran seeks an increased rating. See Claim, July 2009. The Veteran was provided with VA examinations in September 2008, November 2009, April 2012, and April 2013. The September 2008 VA examination report reflects that the Veteran reported that he stopped working in 2003 (as a bus driver) due to knee pain. He did briefly work part-time thereafter driving local shuttles. He chose routes which were unpopular so he would have fewer riders and therefore come into contact with fewer people. He reported hobbies including chess and dominoes. He reported that he rarely goes out, and that going out caused him anxiety. He reported that his sleep was not restful and he experiences nightmares. He reported high anxiety since the war in Iraq, that he experiences panic attacks multiple times per week, particularly around large numbers of people, and that he has a temper and yells a lot but denied physical violence. He reported feeling down daily, being suicidal on and off for many years but without any plan or intent. He reported low interest and motivation, and that he could spend days in his bedroom isolating himself. Mental status examination revealed that the Veteran's mood was anxious, affect was restricted, and his performance on a SLUMS test was 25/30 indicating moderate difficulties with short-term memory and concentration. The examiner noted that the Veteran's social functioning was impaired by the Veteran's high level of anxiety and tendency to isolate himself, and that the Veteran was employable, but only in settings in which he had little or no contact with the public and loose supervision. The examiner recorded diagnoses of PTSD, chronic and moderate, and depressive disorder, NOS, and a GAF score of 52. The examiner opined that the Veteran's overall symptoms caused occupational impairment with reduced reliability and productivity due to symptoms of flattened affect, panic attacks more than once per week, some difficulty with complex commands, impairment of short-term and long-term memory, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The November 2009 VA examination report reflects that the Veteran reported experiencing symptoms of anxiety, depression, decreased interest, decreased motivation, decreased socialization, irritability, passive suicidal thoughts without any active plans, and intermittent panic attacks. He denied homicidal thoughts, auditory or visual hallucinations, or grossly inappropriate behavior. He reported that he has a girlfriend who he stays with several nights a week, and that he lives with his brother. He reported avoiding crowds when running errands, difficulty sleeping, and nightmares. It was noted that he was being treated at the VA medical center, and he reported that the therapy and groups were helpful but the medication was of limited benefit. He reported that he stopped working as a bus driver in 2003 due to physical problems and pain. He reported that when he was working, he generally missed one day per month of work but that was due to physical problems, and that he generally got along with others on the job. Mental status examination revealed the Veteran was neatly groomed, speech was articulate, thought processes were logical and goal-directed, and he scored 25 out of 30 on the St. Louis University Mental Status Exam showing some deficits of short-term memory, attention, and focus. Orientation and long-term memory were grossly intact. The examiner noted that the Veteran continued to have persistent symptoms without any remission in the past year despite counseling and medication. It was noted that the Veteran maintained his personal hygiene, he had no grossly inappropriate behavior, his social functioning was grossly intact, and he experienced irritability. The examiner recorded a diagnosis of PTSD, chronic, mild-to-moderate, and depressive disorder, NOS, mild-to-moderate, and a GAF score of 54. The examiner added that the Veteran's symptoms involved reduced reliability and productivity, he had difficulty leaving the house and being in crowds, and that his difficulties would likely interfere with work performance and interspousal relationships. The April 2012 VA examination report reflects that the Veteran reported that he remained in a relationship with his girlfriend since 1997. He reported that he had not worked since approximately 2003 (as a driver) due to physical problems, including his knees. He reported symptoms including avoiding too many people, a lack of interest in hobbies, sleep impairment and nightmares, frequent panic attacks, significant temper issues, including yelling at his girlfriend (but denied any legal problems or violence issues), and being isolative. He reported that his anxiety and depression worsened since his last examination, and that he was having difficulty mobilizing to do things, but at the same time that his medications for depression have helped him feel better somewhat and to motivate him. He reported that sometimes he skips hygiene and may go for an entire weekend without showering or brushing his teeth. Mental status examination revealed that the Veteran was oriented in all spheres, he was neatly groomed, his thought process was goal directed, his mood is dysphoric, and his affect was restricted. He denied suicidal ideation and reported he believes suicide is a "chicken way out," he denied homicidal ideation, and auditory or visual hallucinations. Additional symptoms noted by the examiner included hypervigilance, suspiciousness, difficulty in adapting to stressful circumstances, including work or a worklike setting, disturbances of motivation and mood, and mild memory loss, such as forgetting names, directions or recent events. The examiner specifically did not indicate that the Veteran was experiencing obsessional rituals that interfere with routine activities, speech that is intermittently illogical, obscure, or irrelevant, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, or an inability to establish and maintain effective relationships. The examiner recorded diagnoses of PTSD and a depressive disorder, NOS, and recorded a GAF score of 54. With regard to the Veteran's level of overall occupational and social impairment, the examiner checked the box indicating occupational and social impairment with reduced reliability and productivity. The examiner did not check the box indicating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The April 2013 VA examination report reflects that the veteran reported that since the last examination he continued to have a romantic relationship with his girlfriend, and that he had one close friend, and he also spends time with his brother-in-law. He reported that he spends most of his time at home because he is too anxious to go out in public, except that he would go to restaurants with his friend. He reported generally having few recreational interests except reading and playing games on the computer. He reported that he stopped working in 2003 due to health problems. He reported a worsening in his PTSD symptoms since the last VA examination that he attributed to coverage on the news to the Boston Marathon bombing and the Aurora theater shootings. He reported that he avoids "nearly everything" because most everything reminds him of Vietnam. The veteran reported that his girlfriend told him that he is not affectionate, and he reported that it is hard for him to be close to other people. He reported experiencing nightmares, irritability (but he denies ever becoming physically violent), he reported that he has no interests, he denied generalized anxiety but reported panicking about going out with his girlfriend in public, He reported that at one time, he had thought about ending his life with the use of a gun, but recognized that it was a "chicken s- way out." He denies suicidal planning, preparatory behaviors, or intent to harm himself. He denied homicidal ideation. Mental status examination revealed that the Veteran was dressed appropriately, his mood was euthymic although he became tearful at times, his affect was mildly restricted, thought was logical and goal-directed, cognitive screening was on the low end of the normal range, and orientation and immediate and working memory were intact. The examiner acknowledged that the Veteran reported at the Board hearing that he had experienced disorientation as to time and place when leaving a restaurant, and that he described suicidal ideation without a specific intent to carry that out. The examiner also noted the Veteran's history of treatment at the VA medical center and that no worsening of his condition was shown in the last several months of mental health records, and no suicidal or homicidal ideation was noted. The examiner administered the PTSD Symptoms Check List, a self report measure designed to assess the frequency and severity of PTSD related symptoms, and the Veteran scored a 40 out of a possible 85. The examiner explained that scores of greater than 50 are considered severe, and the Veteran's score did not exceed the suggested cut off of 50 or the presence and severity cut off for DSM-IV criteria C. The examiner recorded diagnoses of PTSD and a depressive disorder NOS, and a GAF score of 54. The examiner opined that the Veteran's overall symptomatology was moderate, with moderate difficulty in social functioning due to anxiety about going in public and emotional disconnectedness from others, and that his symptoms would likely interfere with occupational functioning in that he would need a non-public facing position where he could perform tasks alone. The examiner further opined that his symptoms involved occupational and social impairment with reduced reliability and productivity. The Board has also taken into consideration the Veteran's VA treatment records, which reflect that he has been followed for individual counseling and medication management, and that he has attended group therapy as well as anger management groups. The Board notes, however, that the symptomatology shown in these records is no more severe than that shown in the above four VA examination reports. Certain of these records are nevertheless discussed in greater detail below. After considering the evidence of record, the Board finds that the preponderance of the evidence is against finding that a higher evaluation is warranted. As shown above, all four VA examiners uniformly opined that the Veteran's overall symptomatology was consistent with occupational and social impairment with reduced reliability and productivity, which is consistent with the present 50 percent rating. As shown above, the medical evidence of record shows that the Veteran has not demonstrated overall symptoms consistent with occupational and social impairment, with deficiencies in most areas, with symptoms such as or similar in severity to obsessional rituals which interfere with routine activities, intermittently illogical, obscure, or irrelevant speech, 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), neglect of personal appearance and hygiene, or an inability to establish and maintain effective relationships. The Board adds that as shown above, the Veteran has maintained a romantic relationship with a girlfriend since 1997, he has a close friend, he spends time with his brother-in-law, and he quit working prior to the period on appeal due to physical problems and not his service-connected PTSD or depression. Although the April 2012 VA examiner did note that the Veteran had difficulty adapting to stressful circumstances (including work or a worklike setting) and suicidal thoughts have been reported, the evidence as a whole shows that there is moderate disability, which more nearly approximates the criteria for 50 percent rather than a higher rating. The Board acknowledges that the Veteran reported at the Board hearing symptoms of suicidal ideation and disorientation on one occasion at a restaurant, and the Board therefore remanded the Veteran's claim for a new VA examination. The Veteran reported to the April 2013 VA examiner that while he had occasional thoughts of death since Vietnam, he recognized that suicide was a "chicken" way out and had no actual plan or intent to follow through. Also, the April 2013 VA examiner noted that mental status examination revealed that his orientation was intact. Similarly, shortly prior to the February 2013 Board hearing and April 2013 VA examination, a January 2013 VA treatment record reflects that the Veteran denied suicidal ideation, and that cognition (i.e., orientation) was intact. Also, while the Board acknowledges that the Veteran reported to the April 2013 VA examiner that he would sometimes skip bathing and brushing his teeth for a weekend, the examiner ultimately found that the Veteran's symptoms did not result in an overall neglect of his personal hygiene, and it was noted that the Veteran presented to the examination dressed appropriately. In rendering this decision, the Board has taken into account the fact that the Veteran's assigned GAF scores have generally been between 52 and 55. According to the GAF scale, scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), and scores from 51 to 59 indicate "moderate" difficulty in social and occupational functioning. The Board adds that the VA examiners have assessed the Veteran's symptomatology as either "moderate" or representing occupational and social impairment with reduced reliability and productivity. The Board finds that the currently assigned 50 percent rating is consistent with moderate symptomatology and, therefore, the Veteran's GAF scores do not warrant a higher rating. While the Board acknowledges that April 2012 and October 2012 VA treatment records reflects a GAF score of 55, it later notes that the "ECH GAF" score was 49. Similarly in February 2012 and July 2012, the "ECH GAF" score assigned was 50. However, the Axis V GAF scores have consistently been 52 or higher. While the GAF scores have been considered, the symptomatology manifested and the severity thereof has not varied to such an extent that a higher rating is warranted during any period of time that is covered by this claim. The Veteran's symptoms of anxiety, sleep impairment, anger, occasional thoughts of suicide, tendency to isolate, depression, decreased motivation, panic attacks or similar symptoms of anxiety, short-term memory impairment, decreased concentration, restricted affect, occasional hygiene problems, and spatial disorientation on one occasion, ultimately result in occupational and social impairment with reduced reliability and productivity. This conclusion is supported by the opinions of multiple VA examiners and the symptomatology reported by the Veteran during VA medical appointments. The Board acknowledges that a September 2010 VA treatment record reflects that this was the Veteran's first appointment with this particular clinician, and the clinician recorded diagnoses of PTSD, severe, depressive disorder, NOS, and a GAF score of 40. The Veteran reported symptoms of nightmares, irritability, depression, anger, isolating and hypervigilance. The Board notes however, that the clinician qualified the note by adding "only met with him for 30 minutes which is simply not enough time to gather a full history for a new patient." Later VA treatment records continued to include the same diagnoses through May 2011 despite noting, for example, that the Veteran "seems to be doing fairly well," that he would brighten up talking about his new house and showed pictures to clinicians, see May 2011, that he was "improving currently, which he is glad about," see May 2011, and he enjoyed his relationship with his girlfriend, see March 2011. Therefore, while the Board acknowledges the use of the word "severe" by a VA clinician, the Board ultimately finds that the symptoms overall have not changed and the ultimate effect on occupational and social impairment has not varied throughout the appeal period. Accordingly, the overall disability picture does not more nearly approximate the criteria for a higher rating. While the Veteran does experience depression and panic, the evidence does not show that it approximates near-continuous panic or depression which affects the ability to function independently, appropriately and effectively or impairment of a similar severity. In addition, while he does experience issues with his anger which may result in outbursts, he has not reported impaired impulse control (such as unprovoked irritability with periods of violence) or symptoms of a similar severity. While he reports that he may neglect his appearance and hygiene on weekends, he has consistently been assessed as having an appropriate appearance and hygiene on medical visits. He also continues to maintain a relationship with his girlfriend and a few other people. While occasional suicidal thoughts are reported, and spatial disorientation was reported on one occasion, this is contemplated in the currently assigned rating and is insufficient to warrant the assignment of a higher rating for any period of time that is covered by the claim. The Board has considered all psychiatric symptoms in reaching the above conclusion. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). The Board has also considered the testimony and lay statements of the Veteran and his friend and finds they are competent, credible and entitled to probative weight. However, after considering the evidence as a whole, the Board finds, as was discussed above, that the criteria for a rating in excess of 50 percent are not met. With respect to the aforementioned Board hearing, the Court of Appeals for Veterans Claims held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts 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, the VLJ noted the current appellate issue at the beginning of the hearing, and asked questions to clarify the Veteran's contentions and treatment history. Following the hearing, the case was remanded in order to obtain additional VA treatment records and to afford the Veteran a VA examination. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. In reaching the above conclusions, the Board also has considered whether the Veteran is entitled to a greater level of compensation for his PTSD with depression on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon 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 that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. The Veteran reported that during his last employment he chose to drive on bus routes that were unpopular to minimize contact with others. An examiner also opined that the Veteran had occupational impairment with reduced reliability and productivity and indicated that he could work in settings in which he had little or no contact with the public and loose supervision. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's PTSD with depression are inadequate. A comparison between the level of severity and symptomatology of the Veteran's psychiatric disorders, as discussed above, with the established criteria shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. While occupational impairment is shown as reported by the Veteran and by the examiners, this impairment is contemplated by the 50 percent criteria as such results in occupational and social impairment with reduced reliability and productivity. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims held that a total disability rating based on individual unemployability (TDIU) is part of a claim for a higher rating when such claim is raised by the record or asserted by the claimant. The Veteran worked as a driver and reported that he stopped working due to physical problems. When he last worked, he chose routes that would minimize contact with others. In this case, TDIU is not raised as the Veteran has not asserted and the other evidence of record does not indicate that he is unable to obtain and retain substantially gainful employment as a result of the service-connected disability. The Board has also considered whether staged ratings are necessary during the appeal period. However, based on the facts found, the current 50 percent rating is appropriate for the entire period on appeal. See Hart, supra. In summary, the Board concludes that a preponderance of the evidence is against granting a disability rating in excess of 50 percent disabling for the Veteran's PTSD with depression; the benefit of the doubt rule is not for application. See 38 U.S.C.A. § 5107(b) (West 2002). ORDER Entitlement to an evaluation in excess of 50 percent disabling for PTSD with depressive disorder, not otherwise specified, is denied. ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs