Citation Nr: 1330273 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 10-08 201 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to an initial disability rating greater than 30 percent for service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from December 1968 to September 1970. His decorations include the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Newark, New Jersey, which awarded service connection for PTSD, assigning an initial 10 percent disability rating, effective January 28. 2009; and which denied service connection for bilateral hearing loss and tinnitus. The Veteran expressed disagreement with the initial 10 percent disability rating for the PTSD, and with the denial of the remaining service connection claims, and perfected a substantive appeal. During the pendency of this appeal, by rating action dated in January 2010, the RO determined that the Veteran's PTSD warranted an initial 30 percent disability rating, effective January 28, 2009. However, a veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). This matter was previously before the Board in April 2012, when it was remanded for additional development. It has now been returned to the Board for further review. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The Veteran's representative notes that the Veteran reported having hypersensitive hearing at his March 2009 VA examination. The representative argues that this is a claim that must be addressed. The Board agrees. As entitlement to service connection for hyperacusis has not been addressed by the RO, this matter is referred to them for initial consideration. FINDINGS OF FACT 1. The Veteran participated in combat, and his reports of exposure to acoustic trauma in the form of combat weaponry noise are presumed to be credible. 2. Competent medical opinion states that it is less likely than not that the Veteran's current hearing loss is related to the acoustic trauma sustained during service. 3. The Veteran does not have a current diagnosis of tinnitus. 4. For the entire period on appeal, the Veteran's PTSD has been productive of occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. Bilateral hearing loss was not incurred due to or aggravated by active service, nor may it be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. Tinnitus was not incurred due to or aggravated by active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2013). 3. The criteria for an initial evaluation of 50 percent, but not higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.126, 4.130, Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and 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) (West 2002); C.F.R. § 3.159(b)(1) (2013). Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In this case, the Veteran was provided with a letter in February 2009 that contained all of the notification required by 38 C.F.R. § 3.159, as defined by Dingess and Pelegrini. This letter was provided to the Veteran prior to the initial adjudication of his claims. As for the claim for a higher initial evaluation for PTSD, the courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board concludes that the duty to notify has been met. The Board further concludes that the duty to assist has also been met. The Veteran's service treatment records have been obtained. Vet Center treatment records have been obtained. He was afforded appropriate VA examinations, and relevant opinions have been obtained from the examiners after a review of the claims folder. The April 2012 remand requested that the Veteran provide additional authorization from Dr. N. P. to obtain medical records, as the previous records obtained from Dr. N. P. were for someone other than the Veteran. The Veteran did not reply to this request. The remaining development requests were contingent on the receipt of records from Dr. N. P. As the Veteran did not submit the records himself or provide additional authorization for VA to obtain them on his behalf, no additional action, including obtaining an addendum medical opinion, was required regarding the remaining development. There is no indication that there is any other relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal. Service Connection The Veteran has submitted a claim for service connection for hearing loss and tinnitus. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Entitlement to service connection for impaired hearing is subject to the additional requirements of 38 C.F.R. § 3.385, which provides that service connection for impaired hearing shall not be established when hearing status meets pure tone and speech recognition criteria. Hearing status will be considered a disability for the purposes of service connection when the auditory thresholds in any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The United States Court of Veterans Appeals (Court) has indicated that the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. However, this method may be used only for the chronic disabilities noted in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Sensorineural hearing loss is considered to be an organic disease of the nervous system, which is one of the disabilities listed in 38 C.F.R. § 3.309. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997) If an organic disease of the nervous system such as sensorineural hearing loss becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of hearing loss during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive, and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that in meeting our responsibility to weigh the credibility and probative value of the evidence, we may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). But, the Board is mindful that it cannot make its own independent medical determinations, and that it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999), and a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as tinnitus, hand pain, and shortness of breath, the Veteran is not competent to provide evidence as to more complex medical questions, as is the case here in determining the etiology of hearing loss. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical profession." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). The Veteran earned the Combat Infantryman Badge. In the case of any veteran who engaged in combat with the enemy during active service, the Secretary shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Therefore, the Veteran's reports of exposure to acoustic trauma in the form of combat weaponry noise are presumed credible. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). While the Board accepts that the Veteran was exposed to acoustic trauma during service, this does not end the analysis as to whether or not service connection for hearing loss is warranted. In addition to an in-service injury, there must still be evidence of a current disability and competent evidence of a relationship between the injury in service and the present disability. In this case, a review of the service treatment records is negative for complaints, treatment or other evidence of hearing loss or tinnitus. The Veteran was afforded an audiometric examination as part of his September 1970 discharge examination. This showed auditory thresholds of 5 decibels or below at every frequency for both ears. The initial post service evidence of hearing loss is on the May 2009 VA audio examination. The examiner reviewed the claims folder and noted the Veteran's history of exposure to combat weaponry noise. On examination, the Veteran denied having hearing loss. He also denied tinnitus, and there was no diagnosis of this disability. The examination showed auditory thresholds of 10, 10, 10, 25, and 50 decibels at the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz for the right ear. The left ear had auditory thresholds of 15, 10, 20, 25, and 50 decibels at these same frequencies. The diagnosis was normal hearing through 3000 Hertz, and moderate sensorineural hearing loss at 4000 Hertz. The examiner opined that the Veteran's hearing loss was not caused by active service, to include military noise exposure. The reasoning provided for this opinion by the examiner is that current scientific evidence asserts that hearing loss related to acoustic exposure or trauma occurs immediately after the insult and has not been found to be present with a progressive onset. Instead, hearing loss with a progressive onset was commonly symptomatic of presbycusis, genetic inheritance, medical pathology, and subsequent civilian noise exposure. The examiner stated that all of the Veteran's military and civilian history had been reviewed and considered in reaching this opinion. He also cited to a medical text in support of the opinion. The Board finds that entitlement to hearing loss is not demonstrated. Although the Veteran undoubtedly was exposed to acoustic trauma during service, there is no competent and credible evidence showing that he developed hearing loss during service or during the first year following discharge from service. The medical evidence is negative for hearing loss. The Veteran does not specifically contend that he had hearing loss during service or within a year of discharge. In June 2009, he made only a general statement that he was in the infantry and had problems with his hearing since returning home. Therefore, hearing loss cannot be presumed to have been incurred during service. Similarly, there is no competent evidence of a relationship between the hearing loss demonstrated at the March 2009 VA examination and the acoustic trauma in service. The examiner opined that there was no relationship, and supported his opinion by citing to the evidence and scientific literature. The Veteran has not offered any specific contentions as to a relationship, and even denied having hearing loss at the examination. In the absence of competent evidence of a nexus between the Veteran's current hearing loss and acoustic trauma in service, service connection for hearing loss is not warranted. Finally, the Board also finds that entitlement to service connection for tinnitus is not demonstrated. The Veteran denied having tinnitus at the March 2009 VA examination, and there are no other medical records that contain a diagnosis of this disability in the claims folder. The Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131 (West 1991); see Degmetich v. Brown, 104 F.3d 1328 (1997), see also Caluza v. Brown, 7 Vet. App. 498, 505 (1995); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v Derwinski, 2 Vet. App. 141, 143 (1992). In the absence of a current diagnosis of tinnitus, there is no basis for service connection. In reaching this decision, the Board notes that the March 2009 VA examiner reviewed medical records that were provided by the Veteran's physician, Dr. N. P., but that these records actually belong to someone else; they are the records of another patient with the same name as the Veteran. These records showed treatment for earaches and temporimandibular joint syndrome, both of which were noted by the examiner. The Board's April 2012 remand attempt to rectify this matter, but as noted the Veteran did not reply. However, the Board finds that review of these records by the VA examiner did not result in any harm to the Veteran. This is because the reasons and bases for the examiner's negative etiological opinion were not related to these records. Instead, it was based on the rationale that current scientific evidence does not support a progressive onset of hearing loss following acoustic trauma. The key evidence of acoustic trauma in service and the delayed onset of hearing loss many years later are accurate. As for the tinnitus claim, the Veteran denied having this disability at the examination. There is no possibility that any harm has resulted to the Veteran as a result of this error, and the Board can proceed with adjudication of the Veteran's claims. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Increased Evaluation The Veteran contends that the initial 30 percent evaluation assigned to his service connected PTSD is inadequate to reflect the impairment that is produced by this disability. He reports sleep difficulties due to nightmares several times a week, the avoidance of crowds and an increased desire for isolation, irritability, hypervigilance, and increased startle response. The evaluation of service-connected disabilities is based on the average impairment of earning capacity they produce, as determined by considering current symptomatology in the light of appropriate rating criteria. 38 U.S.C.A. § 1155. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, the entire history of the veteran's disability is also considered. Consideration must be given to the ability of the veteran to function under the ordinary conditions of daily life. 38 C.F.R. § 4.10. If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. As noted, this issue involves the Veteran's dissatisfaction with the initial rating for his PTSD assigned following the grant of service connection. The Court has found that there is a distinction between a Veteran's disagreement with the initial rating assigned following a grant of service connection, and the claim for an increased rating for a disability in which entitlement to service connection has previously been established. In instances in which the Veteran disagrees with the initial rating, the entire evidentiary record from the time of the Veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability, and staged ratings are to be considered in order to reflect the changing level of severity of a disability during this period. Fenderson v. West, 12 Vet. App. 119 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Entitlement to service connection for PTSD was established in a June 2009 rating decision. A 10 percent evaluation was assigned for this disability, effective from the January 29, 2009 date of receipt of the Veteran's claim for service connection. The evaluation was increased to the current 30 percent rating in a January 2010 rating decision, also effective from January 29, 2009. The Veteran's PTSD is evaluated under the General Rating Formula for Mental Disorders. Under this formula, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought process or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation or own name. The only criteria for a total disability rating for any disability rated in accordance with the VA General Rating Formula for Mental Disorders are total occupational and social impairment. Sellers v. Principi, 372 F.3d 1318, 1324 (Fed. Cir. 2004) A 70 percent evaluation is merited 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 that is 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), and an inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 50 percent evaluation is warranted for 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, and difficulty in establishing and maintaining effective work and social relationships. The current 30 percent evaluation is merited for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Code 9411. The Board is mindful that the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The Veteran's scores on the Global Assessment of Functioning (GAF) scale are another tool used to assess his degree of impairment. GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) [hereinafter DSM-IV]. A 61-70 rating indicates "mild symptoms or some difficulty in social, occupational, or school functioning." A score of 51-60 indicates moderate symptoms, or moderate difficulty in social, occupational or school functioning. A GAF score of 41 to 50 signifies 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). Ibid. The Veteran was afforded a VA examination of his PTSD in May 2009. His subjective symptoms included sleep problems over the years, and he still woke up with cold sweats and dreams in which he was unsure if they were related to his combat experiences. This occurred a few times a week. He reported vivid images and thoughts of Vietnam a few times a week, and he avoided stimuli related to Vietnam. The Veteran admitted to having a lot of irritability and lashing out at his family, with the last episode having occurred several years ago. The Veteran reported having a variable mood, and he often felt detached and numb. He reported vigilance in public places and feeling tense, and reported becoming more isolative. The Veteran denied any suicidal thought or behaviors since leaving Vietnam. In reviewing the Veteran's occupational and social history, he had a master's degree and a doctorate. He had been working in the real estate field for 29 years, and had been self employed for the last 26 years. He had also been married for 26 years and said the relationship was basically good, although he could become very private. He had two children and maintained a generally good relationship with them. The Veteran had interests in several hobbies such as the piano, gardening, kayaking, yoga, and occasional travel. He socialized with his brother-in-laws and had a few friends from his office. The Veteran would occasionally go out to dinner with his wife. He denied any suicidal or violent behavior in the last few years. On mental status examination, the Veteran was neat and well dressed. His eye contact was adequate, no unusual behaviors were noted, and he was pleasant and cooperative. His mood appeared mildly depressed and there was some constriction of affect. Speech was normal, and there was no evidence of hallucinations, delusions, or psychotic symptoms. Thought processes were organized and rational but there was some tangentiality. There was no unusual thought content. Concentration and memory were intact, and insight and judgment were adequate although the later was occasionally impaired by stress. He did frustrate easily. A summary of his symptoms were night sweats and nightmares, some sadness and depression, intrusive thoughts of Vietnam, irritability and mild hypervigilance. He had not experienced a panic attack in 30 years, but did startle easily. These symptoms interfered with his relationship with his wife. He was fairly isolative but did have some social support with some relatives and friends. The Veteran maintained active interests and performed successfully at work. The diagnosis was PTSD, with symptoms that were mild in intensity. His score on the GAF scale was 63. Treatment records from a Vet Center dating March 2010 and April 2010 are in the claims folder. These records show that the Veteran denied suicidal and homicidal thoughts. He appeared anxious but had normal memory. There was no evidence of a thought disorder or depression other than some insomnia and loss of energy. The Veteran reported persistent anxiety with an unknown etiology and sleep disturbances. He tried to reduce his level of anxiety by keeping busy. The Veteran also reported mood fluctuations and exaggerated startle response, as well as previous panic attacks. The Veteran underwent an additional VA examination of his PTSD in June 2010. The claims folder was reviewed by the examiner. The Veteran's subjective complaints continued to include sleep disturbances, memories of Vietnam, and some avoidance behavior such as experiencing discomfort when he attended a recent military reunion. On mental status examination the Veteran was alert and oriented in all spheres. He appeared lethargic but attention and concentration were good. His affect was flat and his speech lacked spontaneity. There were no thought disturbances, hallucinations, delusions, suicidal thoughts, or homicidal thoughts. His insight and judgment were good. The Veteran had consistently been employed on a full time basis for the past 30 years and had his own real estate office. He had been married for 27 years with two children and reported no family issues. The examiner summarized by stating that the Veteran continued to have symptoms but he was able to be gainfully employed and maintain a good quality of life. His primary symptoms were sleep disturbance, some avoidance, and periods in which he struggled with intrusive memories and reminders of his experiences. The diagnosis was PTSD, and the score on the GAF scale was 48. The Board finds that entitlement to an evaluation of 50 percent is warranted for the entire period on appeal. The Veteran has experienced basically the same symptomatology during this period. His most significant symptom appears to be sleep problems several times a week, although he also has some social isolation, intrusive memories, irritability, hypervigilance, and exaggerated startle response. He has been described as anxious and depressed, and his affect as constricted and blunted. In June 2010, he was assigned a GAF scale score of 48, indicating serious symptoms or any serious impairment in social, occupational, or school functioning. The Board concludes that these complaints and findings are commensurate with the assignment of a 50 percent rating under DC 9411. However, the criteria for a 70 percent rating are not met or more nearly approximated at any time during the appellate period. The Board recognizes that the June 2010 VA examiner assigned a GAF of 48, which represents serious symptoms such as suicidal thoughts or serious impairment in social, occupational, or school functioning such as not having any friends. However, this same examiner said that the Veteran maintained a good quality of life, reported that he denied suicidal thoughts, that he had good family relationships, and some friends and social life even with his increased isolation. This examiner also reported that the Veteran had consistently worked full time for the past 30 years at his own business. The Veteran's symptoms, as set forth above, are not of similar severity, frequency, or duration of the kind listed in the 70 percent requirements. The Veteran does not have occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Again, the Veteran has good family relationships and some friends and social life even with his increased isolation and has consistently worked full time for the past 30 years at his own business. While he has symptoms of depression and anxiety, no deficiencies in judgment or thinking have been demonstrated. The record shows that the Veteran is currently employed on a full time basis at his own real estate company. He does not contend and the evidence does not show that his service connected disabilities make him unemployable. Therefore, entitlement to total rating based on individual unemployability due to service connected disabilities is not for consideration in this instance. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Finally, the Board had considered entitlement to an extraschedular evaluation, but finds that one is not merited in this case. The Board finds that the record does not reflect that the Veteran's PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id. Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation as "governing norms", which include marked interference with employment and frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). In this case, the Board finds that the rating criteria to evaluate the Veteran's service-connected PTSD reasonably describes his disability level and symptomatology and he has not argued to the contrary. His most severe symptom is sleep impairment. This is specifically considered in 38 C.F.R. § 4.130, Code 9411, as are the Veteran's other symptoms. These rating criteria reasonably describe the Veteran's disability level and symptomatology, and consequently his disability level is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate. Moreover, the Veteran has not contended that his service-connected disability caused frequent periods of hospitalization or marked interference with his employment and such is not shown by the evidence of record. There is no evidence of a hospitalization, and the Veteran is employed on a full-time basis with no evidence of lost time. For these reasons, the Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to an initial disability rating of 50 percent, but not higher, for service-connected PTSD is granted. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs