Citation Nr: 1329890 Decision Date: 09/18/13 Archive Date: 09/25/13 DOCKET NO. 07-29 629 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for post-traumatic stress disorder (PTSD) prior to November 29, 2010. 2. Entitlement to an increased evaluation in excess of 70 percent for PTSD from November 29, 2010. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on active duty in the United States Marine Corps from September 1967 to January 1970, including service in the Republic of Vietnam. His military decorations include the Combat Action Ribbon and the Purple Heart Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision by the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA), which granted the Veteran service connection and a 30 percent evaluation for PTSD, effective October 31, 2005 (i.e., the date of receipt of his original claim for VA compensation for this psychiatric disorder). The Veteran appeals the initial rating assigned. Consideration must therefore be given regarding whether the case warrants the assignment of separate "staged" ratings for his service-connected PTSD for separate periods of time, from October 31, 2005, to the present, based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). During the pendency of this appeal, a March 2009 rating decision assigned a higher initial rating of 50 percent for PTSD, effective October 31, 2005. In September 2010, the Board remanded this claim to the RO via the Appeals Management Center (AMC) in Washington, D.C., for additional evidentiary development. Following this development, the claim was readjudicated by the RO/AMC. In a December 2011 rating decision, the Veteran was assigned a 70 percent evaluation for PTSD, effective November 29, 2010. The rating decision also confirmed the 50 percent evaluation assigned for PTSD for the period prior to November 29, 2010. (As this increased rating award does not confer the maximum benefit provided in the applicable rating schedule, the case remains in controversy and in appellate status. See AB, Appellant, v. Brown, 6 Vet. App 35 (1993).) Following the December 2011 rating action, the appeal was recertified to the Board and the case was transferred to its custody in January 2012. The Veteran now continues his appeal. FINDINGS OF FACT 1. Prior to November 29, 2010, the Veteran's PTSD was manifested by moderate short-term memory impairment, memory flashbacks, intrusive thoughts, hypervigilence, disturbed sleep, depression, occasional panic attacks, anxiety, anger control impairment, and a tendency towards social isolation, which causes him to lose less than one week of time from work per 12-month period and produces occupational and social impairment with reduced reliability and productivity. 2. From November 29, 2010, the Veteran's PTSD is manifested by nearly daily intrusive thoughts and hypervigilence with associated disturbances in peripheral vision perception, and also disturbed sleep, depression, anxiety, and anger control impairment. The Veteran has a tendency towards social isolation and he loses less than one week of time from work per 12-month period due to PTSD. His PTSD produces occupational and social impairment due to impairment of mood, impulse control, and spatial disorientation, which results in difficulty adapting to stressful circumstances in a work setting. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 50 percent for PTSD prior to November 29, 2010 have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 2. The criteria for an increased evaluation in excess of 70 percent for PTSD from November 29, 2010 have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duty to notify and assist. 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; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice 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). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. The current issues on appeal all stem directly from a claim for an initial evaluation above 50 percent for PTSD, which is itself a downstream issue from a June 2006 rating decision, which initially established service connection for this psychiatric disability and assigned the initial rating being contested and its effective date. The United States Court of Appeals for Veterans Claims (Court) held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006), that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). Thusly, to the extent that there is any defect in, or non-compliance with the statutorily prescribed VCAA notice requirements with respect to the claim for higher initial evaluations for the psychiatric disability now at issue, these deficits are deemed to be non-prejudicial to the claim. VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence with regard to the increased rating claim adjudicated herein. As the claim stems from October 31, 2005, when the Veteran filed his original claim for service connection for the PTSD at issue, the relevant time period and evidence that must be addressed in the adjudication of the claim encompasses the period from the date of claim to the present, in order to allow the Board to consider the applicability of a staged rating. See 38 C.F.R. § 3.400 (2013); Fenderson v. West, 12 Vet. App. 119 (1999). Vet Center and VA clinical records for the period spanning 2005 to 2011, including reports of VA psychiatric examinations dated in May 2006, March 2008 and November 2010, have been obtained and associated with the claims file, or are otherwise viewable on the Virtual VA electronic information database. Additionally, documents from the Veteran's employer regarding disciplinary actions that were taken against him during the pendency of the claim have been submitted by the appellant for inclusion in his claims file. The Board has reviewed the aforementioned VA examination reports and notes that the Veteran's claims file was reviewed by the VA clinicians who performed them, and that these examiners provided adequate discussion of their clinical observations and rationales to support their individual findings and conclusions within the context of the Veteran's pertinent clinical history as contained within his claims file. The examinations are therefore deemed adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board notes that the Veteran's last psychiatric examination is now nearly three year old. The mere passage of time since that examination is not reason enough, alone, to require reexamination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Here, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's PTSD since the most recent examinations. The Veteran has not argued the contrary. In its remand of September 2009, the Board instructed the RO/AMC to obtain all outstanding relevant VA treatment records and then schedule the Veteran for a psychiatric examination to assess the current state of his PTSD. A review of the claims file shows that the RO/AMC has substantially complied with the Board/s remand instructions. Thusly, an additional remand for corrective action is unnecessary. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the Veteran in the evidentiary development of the claim decided herein, and thus no additional assistance or notification is required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. 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. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased ratings for psychiatric disabilities - generally. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2013). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2013); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2013). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2013). The Veteran has been clinically diagnosed with PTSD that was linked to stressors that occurred in service while serving in Vietnam, consistent with his participation in combat during active duty, which his service department recognized by bestowing upon him the Combat Action Ribbon and the Purple Heart Medal. By rating decision dated in June 2006, he was granted service connection for PTSD, effective October 31, 2005. This disability is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). Diagnostic Code 9411 provides that PTSD is evaluated under the general rating formula used to rate psychiatric disabilities other than eating disorders. 38 C.F.R. § 4.130 (2013). The Veteran's service-connected psychiatric disorder is currently evaluated as 50 percent disabling prior to November 29, 2010, and 70 percent disabling from November 29, 2010. Although the Veteran's treatment records reflect that Axis I psychiatric diagnoses other than PTSD are sometimes presented, the Court in Mittleider v. West, 11 Vet. App. 181 (1998), has essentially held that such additional Axis I diagnoses be attributed to the service-connected psychiatric disability as the primary underlying condition. 61 Fed. Reg. 52,698 (Oct. 8, 1996). A 50 percent rating for PTSD is warranted when there is 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. A 70 percent rating for PTSD is warranted where there is 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. A 100 percent rating for PTSD is warranted where there is 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. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2012). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Federal Circuit emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). It held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). (a.) Entitlement to an initial evaluation in excess of 50 percent for PTSD prior to November 29, 2010. The relevant clinical evidence pertaining to treatment and evaluation of the Veteran's PTSD for the period from October 2005 to November 28, 2010, includes Vet Center and VA outpatient treatment and examination reports, which reflect that the Veteran's PTSD was manifested by nightmares, intrusive thoughts, and occasional memory flashbacks of his combat experiences, with associated hypervigilence, exaggerated startle reaction, sleep impairment, persistent feelings of anger, depression, irritability, and anxiety. Occasional panic attacks without agoraphobia were reported. Mild remote memory impairment and moderate recent memory impairment was indicated. The Veteran was divorced and had few friends. He avoided crowded environments and preferred solitude and social isolation when he was not working. Mental status examinations in May 2006 and March 2008 show that he was well-dressed, well-groomed and displayed good personal hygiene. He was alert with good energy and oriented on all spheres. Speech was normal in tone, regular in rate, and coherent. He displayed good eye contact with the examining clinician and interacted appropriately. His mood was restless. He displayed high intelligence and his thought content did not present any psychotic symptoms or suicidal or homicidal ideation. His affect was serious and anxious. He was cognitively intact and capable of insight and judgment. He did not appear to be particularly avoidant of stimuli associated with his Vietnam War experiences or of combat; to the contrary, he appeared to be actively interested in observing these subjects. He was competent to handle his own funds. The diagnosis was PTSD. The Veteran's Global Assessment of Functioning (GAF) scores for the entire period prior to November 29, 2010, ranged from being occasionally as low as 45 and up to as high as 60, but were predominantly in the 55 - 60 range, indicating moderate social and occupational impairment (e.g., few friends, conflicts with peers or co-workers). See American Psychiatric Association's Diagnostic and Statistical Manual, 4th edition (DSM-IV). The clinical records indicate that the Veteran lost less than one week of work during a 12-month period due to his PTSD symptoms. The March 2008 VA examination report also notes that although the Veteran's poor impulse control made him prone to verbal altercations with his peers and co-workers, these did not escalate into episodes of physical violence. The documentary and clinical evidence indicates that the Veteran earned a bachelor's degree in science (BS) and a master's degree in business administration (MBA), and that he was employed on a full-time basis in professional sales. He experienced impaired control of his temper, which resulted in occasional angry outbursts, aggressive behavior, and friction with his co-workers. Letters of reprimand from his employers and dated in January 2007 note, in pertinent part, that the Veteran was disciplined for displaying an excessive temper, foul language, inappropriate behavior in a professional environment, and aggression towards his co-workers. However, the supervisor also acknowledged that the Veteran's quality of work was otherwise fully satisfactory and met the company's yearly objectives and also that he was deemed to be a valuable employee and an asset to the continuing success of the company. In an October 2010 e-mail to the Veteran, his supervisor stated that while he acknowledged that the Veteran was capable of producing decent quality work, he was concerned of recent changes in the Veteran's demeanor at the workplace, particularly that he had become significantly short-tempered and quick to anger and prone to frustration and self-blame, even for some issues that were outside of his control and responsibility. The supervisor advised the Veteran to cooperate with management to accommodate or support him as these problems were hindering his work performance and increasing the level of stress for his co-workers. VA clinical records for the period from October 2005 to November 28, 2010, reflect that the Veteran had been prescribed psychotropic medications for his PTSD and that he had never been psychiatrically hospitalized for PTSD. He remained employed on a full-time basis. The Board has considered the aforementioned evidence and concludes that the initial 50 percent evaluation assigned for PTSD for the period commencing October 31, 2005 to November 28, 2010 adequately compensates the Veteran for the state of his social and occupational impairment due to this psychiatric disability for this period. The relevant evidence demonstrates that for the period prior to November 29, 2010, the psychiatric symptoms attributable to the Veteran's PTSD are primarily manifested by irritability, anger control impairment, sleep disturbance, and moderate short-term memory impairment, which produce social and occupational impairment with reduced reliability and productivity due to disturbances in mood that results in difficulty establishing and maintaining effective work and social relationships. The Veteran was oriented on all spheres and not suffering from hallucinations or psychotic symptoms and he was able to communicate appropriately with the examiner. The clinical evidence generally demonstrates no more than moderate social and occupational impairment, as indicated by the corresponding GAF scores that were predominantly in the range of 55 - 60 during the period (see 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the American Psychiatric Association's DSM-IV, for rating purposes). Notwithstanding the Veteran's demonstrated capacity to work full-time during the period at issue with less than a week of time lost due to PTSD, the Board must take into account that the clinical picture presented indicates that he is impaired by his anger control problems, which resulted in his being reprimanded by his workplace supervisor in 2007. His supervisor's letters of discipline indicate that the Veteran's PTSD produces definite impairment of his ability to function effectively with his co-workers due to his aggression and short temper. With this in mind, however, the evidence does not demonstrate that the Veteran is a danger to himself much less to others as he has no suicidal or homicidal ideation or propensity for physical violence. Thus, his persistent difficulty sleeping, depressed and anxious mood, irritability, sporadic panic attacks, short-term memory impairment, impaired concentration ability due to intrusive thoughts and memory flashbacks, and the social and occupational impairment imposed by his socially avoidant tendencies and his anger control impairment, when taken as whole, collectively support the assignment of a 50 percent evaluation as these symptoms more closely approximate the criteria for a 50 percent evaluation for social and occupational impairment with reduced reliability and productivity. The totality of the clinical evidence, however, indicates that the Veteran remained capable of generally effective or at least satisfactory interpersonal functioning and communication. As previously stated, the overall disability picture presented by the relevant psychiatric evidence more closely approximates the criteria contemplated in a 50 percent evaluation for PTSD for psychiatric symptoms producing reduced reliability and productivity. The clinical evidence does not otherwise demonstrate that the Veteran's PTSD is manifested by symptomatology that more closely approximates the criteria for a 70 percent or higher evaluation under Diagnostic Code 9411 prior to November 29, 2010. The criteria listed for a 70 percent evaluation contemplate social and occupational 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. The Board is mindful to avoid rating the Veteran's PTSD by mere rote and concrete application of the aforementioned examples listed in the rating schedule to the facts of the present case, but rather to consider the Veteran's social and occupational impairment in view of the entirety of the relevant evidence. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In the Board's assessment, within the context of the entire record, his moderate short-term memory impairment, anger control problems, and disturbances of motivation and mood are deemed to have been adequately contemplated in the criteria for a 50 percent evaluation on the basis that his psychiatric symptoms would produce only reduced reliability and productivity in an occupational setting. Indeed, entitlement to a 70 percent rating "requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazques-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Such is not demonstrated. The Veteran has not lost a significant time from work due to PTSD and remains objectively capable of a level of social and occupational functioning that more closely approximates the criteria for a 50 percent evaluation, in keeping with his ability to maintain full-time employment despite his propensity to isolate himself socially after work. The Board thusly concludes that the Veteran's psychiatric manifestations of PTSD for the period from October 31, 2005 to November 28, 2010 are of insufficient severity to produce the level of social and occupational impairment contemplated by a 70 percent evaluation. In view of the foregoing discussion, the Veteran's claim for an initial evaluation in excess of 50 percent for PTSD for the period prior to November 29, 2010 must be denied. Because the evidence in this case is not approximately balanced, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (b.) Entitlement to an increased evaluation in excess of 70 percent for PTSD from November 29, 2010. VA psychiatric examination conducted on November 29, 2010, shows that the Veteran continued to be employed on a full-time basis, losing only less than a week of time from work in the previous 12-month period due to medical appointments to address his PTSD. A GAF score of 45 was acknowledged in the report, indicating serious social and occupational impairment (e.g., no friends, unable to keep a job). The Veteran lived alone. When not at work, he avoided contact with others as he was generally mistrustful of, and easily irritated by other people. Mental status examination indicated that he was oriented on all spheres and presented a clean and neatly groomed appearance with appropriate attire. His attitude towards the examiner was cooperative and his speech was clear, coherent and spontaneous. His affect was blunted and he was tense during the interview. Some concentration difficulty was indicated as he was easily distracted due to hypervigilence and peripheral vision distortion, but he was able to perform serial 7's. Hypervigilence produced obsessive behavior such as frequently checking the doors and locks of his home. No thought disorder, delusions, or psychotic symptoms were indicated. He had insight into his problems. He reported having sleeping problems due to nightly-occurring nightmares, intrusive thoughts and memory flashbacks relating to his combat stressors. Inappropriate behavior such as aggressive confrontation of others due to referential thoughts associated with PTSD was indicated. He easily lost his temper and was given to violence on occasion, but no homicidal ideation was indicated. He reported that he experienced suicidal thoughts one per month, but without plan or intent. The report indicated that the Veteran's response to his PTSD was to avoid stimuli that would remind him of his stressors. His PTSD imposed severe restrictions on his ability to shop for himself and engage in recreational activities, and moderate restrictions on his ability to operate a motor vehicle and drive himself. He experienced anxiety in crowds and visual distortions in his peripheral vision of what he perceived as combat-like situations in public and at work. Episodic depression was also reported. Frequency of the aforementioned symptoms was almost daily, the episodes were moderate to severe in intensity, and lasted for a few hours to all day. VA treatment records dated in June and September 2011 show ongoing pharmacotherapy for PTSD and a GAF score of 55, indicating moderate social and occupational impairment. The reports indicate that the Veteran continued to be employed on a full-time basis. Interestingly, notwithstanding the November 2010 report indicating that the Veteran's response to his PTSD was to avoid exposing himself to stimuli that would remind him of his stressors, the reports show that he was actively planning to travel to China, Southeast Asia, and Vietnam, which he wanted "to be a closing event for him." The Board has considered the evidence relevant to the period commencing on November 29, 2010, and finds that the 70 percent evaluation assigned to the Veteran's PTSD adequately compensates him for his level of social and occupational impairment due to his psychiatric disability. His nearly daily episodes of PTSD-induced anxiety symptoms with peripheral vision disturbance and his easily provoked temper are consistent with the criteria for a 70 percent evaluation for occupational and social impairment with deficiencies in mood due to impaired impulse control, spatial disorientation, and difficulty adapting to stressful circumstances in a work-like setting. However, he does not meet the criteria for a 100 percent schedular evaluation under Diagnostic Code 9411, and the clinical evidence does not demonstrate that he has total occupational and social impairment. His PTSD is not presently manifested by symptoms such as gross impairment in his thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; 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 own name. Although he was reported to be occasionally given to violence due to his anger and aggressively confrontational tendencies, the evidence does not show actual homicidal ideation on his part and only occasional suicidal ideation once per month, but without plan or intent. The Board cannot concede that the Veteran's PTSD causes the Veteran to be a persistent danger of hurting himself or others. Therefore, the 70 percent evaluation assigned for PTSD for the period commencing on November 29, 2010 is appropriate. In view of the foregoing discussion, the Veteran's claim for an evaluation in excess of 70 percent for PTSD for the period from November 29, 2010 must be denied. Because the evidence in this case is not approximately balanced, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (c.) Individual unemployability and extraschedular consideration. Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board must consider the assignment of a total rating for individual unemployability (TDIU) as part and parcel to the increased rating claim for PTSD on appeal. The Board notes that the Veteran is present service connected for PTSD (rated 70 percent disabling), Type II diabetes mellitus (rated 20 percent disabling), hypertension (rated noncompensable) and erectile dysfunction (rated noncompensable, but with special monthly compensation for loss of use of creative organ under 38 U.S.C.A. § 1114(k) (West 2002)), which produce a combined rating under 38 C.F.R. § 4.25 of 80 percent. As such, they meet and exceed the minimal criteria for a TDIU under 38 C.F.R. § 4.16(a) (2013). However, notwithstanding the documented evidence from the Veteran's employers indicating that his PTSD-related temper control problems interfere with his ability to function effectively with his co-workers, the clinical evidence nevertheless clearly demonstrates that the Veteran is currently employed on a full-time basis. Simply put, a TDIU claim has been either expressly or implicitly raised by the record. The Board further finds that there is no evidence of an exceptional or unusual disability picture associated with the Veteran's service-connected PTSD, with such related factors as marked interference with employment or frequent periods of psychiatric hospitalization, as to render impractical the application of the regular schedular standards. A rating in excess of the assigned schedular evaluation for the Veteran's service-connected PTSD may be granted when it is demonstrated that the particular disability presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2013). The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2013) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. See Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. See Shipwash v. Brown, 8 Vet. App. 218, 277 (1995). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board finds that there is no evidence that the Veteran's service-connected PTSD has presented such an unusual or exceptional disability picture at any time between October 2005 to the present, so as to require consideration of an extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b) (2013). Specifically, the evidence of record does not indicate the Veteran is frequently hospitalized for his service-connected psychiatric disability. The record indicates that the Veteran was able to work full-time in a professional occupation during the entire pendency of the claim. Although the PTSD imposed difficulties in his ability to govern his mood, which produces impairment of his ability to effective function with his co-workers, the clinical and documentary evidence does not indicate marked interference with his ability to work in his current place of employment. The criteria of the applicable rating schedule is therefore deemed to adequately contemplate the Veteran's present level of impairment due to PTSD for the staged rating periods at issue, as individually considered. As such, the Board cannot concede that the Veteran's service-connected psychiatric disability, standing by itself, causes marked interference with his employment capacity. Higher ratings are available for the Veteran's PTSD, but for the reasons described in the above decision, higher ratings were denied in this case. The clinical evidence and medical opinions fail to show that the disability picture created by this psychiatric disability, in isolation, is of an exceptional or unusual nature. Having reviewed the record with these mandates in mind, the Board finds that the schedular ratings presently assigned to the PTSD for the time periods at issue adequately reflect the state of its impairment for the periods to which they are applied, and that there is no evidentiary basis for referral of the case for extraschedular consideration with regard to this matter. (CONTINUED NEXT PAGE) ORDER An initial evaluation in excess of 50 percent for PTSD prior to November 29, 2010 is denied. An increased evaluation in excess of 70 percent for PTSD from November 29, 2010 is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs