Citation Nr: 1330082 Decision Date: 09/19/13 Archive Date: 09/25/13 DOCKET NO. 10-25 177 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: David L. Huffman, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. Joyner, Counsel INTRODUCTION The Veteran served on active duty from June 1967 to June 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The July 2009 rating decision denied entitlement to service connection for bilateral hearing loss and tinnitus, and granted service connection for PTSD and assigned a 30 percent rating, effective May 7, 2008. The Veteran appealed the denials of service connection for bilateral hearing loss and tinnitus, as well as the initial 30 percent rating assigned for PTSD. In December 2011 the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing at the RO. A copy of the transcript of that hearing has been associated with the claims file. When the case was last before the Board in March 2012, the Board dismissed the appeals for the issues of entitlement to service connection for bilateral hearing and tinnitus, as the Veteran withdrew his appeals for those claims at the Travel Board hearing. Also in March 2012, the Board remanded the issue of entitlement to an initial rating in excess of 30 percent for PTSD. In a January 2013 rating decision, the RO granted an increased rating of 70 percent for PTSD, effective May 7, 2008. As the Veteran is in receipt of less than the maximum schedular rating for this disability, the matter remains in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). FINDING OF FACT Throughout the initial evaluation period the Veteran's PTSD is manifested by occupational and social impairment with deficiencies in most areas; but not by total occupational and social impairment. CONCLUSION OF LAW The criteria for an initial rating in excess of 70 percent PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). June 2008 and January 2009 letters satisfied the duty to notify provisions, to include notifying the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. 38 U.S.C.A. § 5103(a) ; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the initial rating of the disability on appeal, as the Veteran did in August 2009 with respect to his PTSD, does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, any defect as to notice is non-prejudicial. See id; Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 134 (2008) (where a claim has been substantiated after August 29, 2000, the appellant bears the burden of demonstrating any prejudice from defective notice with respect to any downstream elements). VA examinations were conducted in April 2009, June 2009, and December 2012; the Veteran has not argued, and the record does not reflect that these examinations were inadequate for rating purposes. The examinations were adequate because they were based on an examination of the Veteran and provided sufficient information to address the rating criteria for the disability on appeal. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). There is no indication in the record that any additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) recently held that 38 C.F.R. 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) the duty to fully explain the issue or issues on appeal and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the Veteran was assisted at the Board hearing by a private attorney. During the Veteran's hearing, the Veteran's attorney asked the Veteran questions about his symptoms and severity of his PTSD and the VLJ asked the Veteran questions about his treatment for his PTSD. Neither the Veteran nor his attorney has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing. As such, the Board finds that the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2), consistent with Bryant, and that any error in notice or assistance provided during the Veteran's hearing constitutes harmless error. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, the Board is satisfied as to compliance with the instructions from its March 2012 remand. Specifically, the March 2012 Board remand instructed the RO to obtain and associate with the claims file any VA treatment records and examination reports from the VA Medical Center in Bay Pines, Florida and all associated outpatient clinics from June 2009 to the present. The RO was also instructed to request information from the Veteran regarding his treatment from a Dr. Ford and Dr. Sherman, as well as ask the Veteran to identify any other doctors who have treated him for his disability. The RO obtained the requested VA treatment records and sent the Veteran a letter in August 2012 which requested the above information regarding private treatment. In April 2012 the Veteran submitted additional private medical evidence. Moreover, the Veteran was afforded an additional VA examination in December 2012. The Board finds that the RO has complied with the Board's instructions and that the development undertaken by the RO on remand substantially complies with the Board's March 2012 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Legal Analysis Increased Initial Rating Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Where the Rating Schedule does not provide for a noncompensable evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Service connection for the Veteran's PTSD was granted in a July 2009 rating decision. An initial 30 percent rating was assigned, effective May 7, 2008, under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. Thereafter, in a January 2013 decision, the RO increased the rating for the Veteran's service-connected PTSD to 70 percent, effective May 7, 2008. Therefore, the Veteran's PTSD is rated as 70 percent disabling throughout the initial evaluation period, under Diagnostic Code 9411. Diagnostic Code 9411 is subsumed into the General Rating Formula for Mental Disorders (General Rating Formula). Under the General Rating Formula, a70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted where there is evidence of 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. One factor to be considered is the GAF score which is 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 11 to 20 indicates that there is some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement), or an occasional failure to maintain minimal personal hygiene, or gross impairment in communication. A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A GAF Score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant), or where there is 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). A GAF of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., few friends, unable to keep a job). A GAF of 51 to 60 indicates moderate symptoms (e.g., flattened 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 of 61 to 70 indicates some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or social functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. 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. Accordingly, GAF scores do not automatically equate to any particular percentage in the Rating Schedule. Rather, they are but one factor to be considered in conjunction with all the other evidence of record. At the outset, in addition to PTSD, the medical evidence reflects diagnoses of depression, generalized anxiety disorder, and dysthymic disorder. Although the December 2012 VA examiner actually indicated that it was possible to differentiate what portion of each symptom is attributable to each diagnosis, the examination report does not actually distinguish the symptoms of each diagnosis. The examiner merely stated that the Veteran's chronic anxiety and depression symptoms have been continuous, progressive, and are biologically and behaviorally interactive and concurrent. The December 2012 VA examiner checked off multiple symptoms that apply to the Veteran's various diagnoses, but then added that there were no other symptoms beyond those checked that are attributable to his PTSD and other mental disorders, without distinguishing which symptoms are related to which diagnosis. However, the April 2009 VA examiner stated that the Veteran's depression causes more impairment in quality of life than the PTSD symptoms. Further, the examiner indicated that the Veteran's depression leads to depressed mood, hopeless, worthless and guilty feelings, anhedonia, and suicidal ideas. PTSD was noted to lead to irritability, intrusive thoughts of combat, and increase startle response. Both diagnoses were noted to cause poor concentration, anxiety and insomnia. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). While the July 2009 rating decision granted service connection for PTSD alone, the June 2009 VA examiner essentially opined that the Veteran's depression (which the examiner felt should be diagnosed as dysthymic disorder late onset), was initially experienced as the result of combat-related traumatic events. Consequently, all of his psychiatric symptoms have been considered in evaluating his service-connected PTSD. The medical evidence of record includes an April 2009 VA examination report which notes that the Veteran completed hair styling school, and obtained his real estate license and mortgage and community association license. It was noted that the Veteran has a good rapport with his siblings and that he was twice divorced in part due to irritability, temper problems, and nightmares. It was noted that he has had close personal friends and that he currently has five or six friends whom he sees or speaks with regularly. However, he seldom participates in social activities. It was also noted that he was living with his girlfriend, and that he had been living with her for the past five months. He described spending his time looking for work, volunteering at church and at Big Brothers and Big Sisters, and reading and watching television. It was noted that he had no history of suicide attempts and no history of violence or assaultiveness since the 1970s. The examiner summarized that the Veteran lives with his girlfriend, does volunteer work, has some friends, and his main stressor has been financial losses from his business of real estate management. Mental status examination revealed that the Veteran was clean, neatly groomed, and casually dressed. He was restless and tense. His speech was spontaneous, clear and coherent. His attitude was cooperative and his affect was intense. His mood was anxious and depressed, irritable at times. His attention was disturbed in that he was easily distracted. He was fully oriented and his thought process was unremarkable. His thought content was noted to be preoccupied with one or two topics. There were no delusions. Judgment and insight were intact. There was sleep impairment, but no hallucinations, inappropriate behavior, or obsessive/ritualistic behavior. It was noted that the Veteran has panic attacks at variable frequency, the last of which was nine months earlier. There were no homicidal thoughts but there were suicidal thoughts. His impulse control was noted to be fair, and there were no episodes of violence. He was noted to be able to maintain his minimum personal hygiene. There was no problem with activities of daily living. His memory was intact. The examiner noted that the Veteran was currently unemployed as of two weeks prior to the examination. The Veteran stated that his usual occupation was real estate management. His reason for unemployment was noted to be that he had previously held a seasonal job managing a property. The Veteran did not contend that his unemployment was due to his PTSD. It was noted that Veteran's GAF score was 65. The examiner opined that the Veteran's current unemployment was not related to PTSD, but also noted that poor concentration may reduce work efficacy, and anxiety, periods of irritability, sleep loss, and intrusive thoughts cause impairment in quality of life. The examiner opined that the Veteran does not have total occupational and social impairment, but that PTSD signs and symptoms result in deficiencies in thinking, family relations, work, and mood, but not judgment. The June 2009 VA examination report notes that the examiner reviewed the claims file. The examiner opined that the Veteran has experienced symptoms of PTSD since returning from combat deployment in Vietnam. Moreover, the examiner indicated that the Veteran has experienced depressive symptoms periodically during his adult life, particularly related to personal relational losses such as his second divorce and the deaths of fellow Army personnel in Vietnam. The examiner noted that the Veteran first experienced depressive symptoms following his return from Vietnam related to loss of fellow soldiers. The examiner went on to state that these depressive symptoms coincided with his PTSD symptoms and have persisted throughout his adult life. Although a diagnosis of depressive disorder was made at a prior examination, the current VA examiner felt that the Veteran should be diagnosed with dysthymic disorder. The examiner stated that while notably suffering to variable degrees from his PTSD and dysthymic disorder, the Veteran has not been substantially impaired occupationally. A January 2010 VA treatment record notes that the Veteran's behavior was within normal limits, as was his speech. His mood was euthymic and his affect was constricted and irritated. No disturbance in thought process was reported or observed. His thought content was appropriate and organized. His insight and judgment were good. He denied suicidal or homicidal ideation. His GAF score was 65. A September 2010 VA treatment record notes that behavior and speech were within normal limits. His mood was dysthymic and his affect was constricted and flat. There was no disturbance reported or observed in his thought process and his thought content was noted to be appropriate and organized. His insight and judgment were determined to be good and he denied suicidal and homicidal ideation. It was noted that he believed he reached his therapeutic goal in that his non-circumstance related insomnia, depressed mood, anxiety, and low energy have remitted. However, he reported that his nightmares persist. His diagnoses were PTSD and major depressive disorder, moderate. His GAF score was noted to be 65. A March 2012 private psychological assessment indicates that the Veteran was late for his appointment because he was lost. On examination it was noted that he had average grooming and his speech was clear. His eye contact was good but his affect was anxious and sad. He took numerous breaks when talking about Vietnam. He was fully oriented. Responses to structured questions assessing judgment and common sense reasoning skills were accurate in three out of our scenarios suggesting he may not always use his best judgment and common sense reasoning skills. He described his usual mood as being pretty good. However, he stated that his nightmares are worse than combat. He reported strong feelings of guilt about the war. He denied hallucinations and persecutory ideations. He reported never attempting suicide and denied current suicidal ideation. He reported having difficulty getting close to anyone and becoming emotionally involved with anyone since Vietnam. He reported not having enough energy to do anything or be interested in anything. The diagnoses were PTSD, severe symptoms, major depressive disorder, severe, and generalized anxiety disorder. His GAF score was noted to be 45. At the October 2011 Travel Board hearing the Veteran indicated that he had two seasonal part-time jobs. He also indicated that he previously did some consulting work and that before that he had a real estate mortgage business but that he had to close the business due to the economy. An October 2011 VA treatment record notes that the Veteran reported finally seeing a "light at the end of tunnel." He stated that he had called his friend days earlier and told him about having a suicidal thought. His friend sent the police to check on him. He stated that he is currently not having any suicidal ideation. He was with his sister, who accompanied him as support. He voiced a negative attitude toward his financial status and focused mostly on that. Mental status examination revealed that he was well groomed. His speech was normal. He did not have abnormal movements or tremors. His speech was normal and his mood and affect were euthymic. He denied delusions, auditory or visual hallucinations, and suicidal or homicidal ideations. He was alert and oriented, his cognition appeared intact, and he was found to have full insight and good judgment. His GAF score was noted to be 58. A December 2011 VA treatment record reflects the Veteran's statement that he had just found seasonal employment which was very demanding. A June 2012 letter from the Veteran's sister indicates that the Veteran shut down his real estate office in 2003 and is unable to work. A July 2012 VA treatment record notes that the Veteran denied suicidal and homicidal ideation. On examination he was pleasant and cooperative. He did not have abnormal movements or tremors. His speech was normal and his mood and affect were euthymic. He denied delusions, auditory or visual hallucinations, and suicidal or homicidal ideations. He was alert and oriented, his cognition appeared intact, and he was found to have full insight and good judgment. His GAF score was noted to be 65. A November 2012 VA treatment record reflects the Veteran's complaint of lack of energy, lack of motivation, and high anxiety levels. Mental status examination revealed no abnormal movements, normal speech, euthymic mood, and euthymic affect. He denied delusions, and auditory and visual hallucinations. He also denied suicidal and homicidal ideation. He was alert and fully oriented. Cognition, insight and judgment were found to be intact. His GAF score was noted to be 65. The December 2012 VA examination report notes that the Veteran has experienced continuous and progressive PTSD symptoms which have limited his psychosocial and occupational functioning. It was noted that with lessened mobility due to polyarthritis, he has become more socially withdrawn. He noted daily insomnia, recurrent nightmares and intrusive memories, exaggerated startle response, hypervigilance, irritability, mood dysphoria, decreased concentration, anxiety with socially avoidant behaviors, and emotional detachment. It was reported that he now spends significantly more time reading about and watching television documentaries about Vietnam. He has withdrawn from prior volunteer and other interactive activities. The examiner noted that the Veteran has had variable depression symptoms since his combat tour in Vietnam. His depression symptoms have worsened during periods of stress and over time the cumulative effects of his business pressure, divorces, separations in personal relationships, financial stressors, etc., have significantly worsened his depression symptoms. It was noted that the Veteran has been divorced twice. He has occasional phone contacts with his brother and sister, as well as a small number of high school friends. However, he has progressively withdrawn from previously meaningful social interactions (volunteering at Big Brothers, Big Sisters and church activities). He lives alone and spends almost all of this time in and around his apartment. It was noted that he closed down his real estate-mortgage business in 2009 during the economic recession and has worked part time during the past year assisting a man who publishes a professional journal. He reportedly finds it increasingly difficult to perform this work because of somatic pains, decreased capacity for concentration, fatigue, and irritability. The examiner noted that the Veteran's symptoms include depressed mood, anxiety, suspiciousness, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including a work or worklike setting, suicidal ideation, impaired impulse control, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner did not find the Veteran unable to establish and maintain effective relationships. The examiner provided a GAF score of 55. A January 2013 VA treatment record notes that the Veteran denied suicidal and homicidal ideation. After reviewing the evidence, the Board finds that throughout the initial evaluation period, the Veteran has deficiencies in most of the areas of work, family relations, judgment, thinking, and mood due to his service-connected PTSD. However, a higher, 100 percent rating is not warranted at any time during the initial evaluation period because the evidence does not show that the social and occupational impairment from the Veteran's PTSD is total. The Board recognizes that the Veteran was not employed full-time throughout the initial evaluation period. However, the April 2009 VA examination report reflects that although the Veteran was then currently unemployed, he did not allege that he was unemployable due to his PTSD. While the evidence does show that the Veteran has deficiencies at work, evidenced by his impaired impulse control, irritation, concentration problems, reduced memory and isolation, and at the December 2012 VA examination, the Veteran reported increasing difficulty performing his part-time employment duties due to some of these symptoms, the evidence does not specifically show that the Veteran was totally occupationally impaired due to his PTSD. Importantly, his speech was consistently normal, his thought processes were consistently normal, and his thought content was consistently negative for perceptual disturbances or delusional material. Additionally, the Veteran is not totally socially impaired. In April 2009 the Veteran was reportedly living with his girlfriend, volunteering at church and the Boys and Girls Club, having close friends, and speaking to or seeing five or six friends regularly. Although his social impairment was noted to be much worse at the time of the December 2012 VA examination, he was still reportedly speaking occasionally on the phone to both his brother and sister, as well as s a small number of high school friends. Moreover, his sister attended an October 2011 VA mental health appointment with him in order to show support of him. The Board acknowledges that he was living alone at the time of the December 2012 VA examination and he had withdrawn from his volunteering positions with Big Brothers Big Sisters and church activities; however, he was not totally socially isolated. Finally, while his GAF score has been as low as 45 (according to the private psychological assessment dated in March 2012), it has generally been between 55 and 65, which does not support impairment more nearly approximating a 100 percent rating. In sum, the Veteran's PTSD is severe during the initial evaluation period, and it has caused severe occupational and social impairment, but it has not caused total social or occupational impairment because the evidence does not show that his PTSD precludes him from working or relating to his family members and friends. Other Considerations An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321(b) (1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The Board finds that the schedular rating for the Veteran's PTSD is adequate. A rating in excess of the assigned rating is provided for a higher level of severity of PTSD, but such a rating is for certain manifestations which the medical evidence reflects are not present in the Veteran's clinical picture. The diagnostic criteria also adequately describe the severity and symptomatology of the Veteran's PTSD. Therefore, the Veteran's disability picture is contemplated by the Rating Schedule; no extraschedular referral is required. In sum, the record does not reflect that the Rating Schedule is inadequate to contemplate the manifestations of his PTSD. Thus, no extraschedular referral is required. Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service- connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that his service-connected disability at issue renders him totally unemployable. The Board recognizes that the Veteran's sister stated that the Veteran cannot work, but the Veteran has not alleged that he is unemployable due to his PTSD, and the record consistently reflects that the Veteran has maintained some form of employment during the initial evaluation period. In fact, in December 2011 the Veteran indicated that he had gotten a job that was very demanding. He did not indicate he was unable to perform the demanding work. His usual employment in real estate management ended due to the economy and he has not indicated that his PTSD has rendered him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. ORDER Entitlement to an initial rating in excess of 70 percent for PTSD is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs