Citation Nr: 1331364 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 09-36 971A ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an initial rating in excess of 10 percent prior to March 2, 2009, in excess of 30 percent from March 2, 2009, and in excess of 70 percent from February 27, 2012, for posttraumatic stress disorder (PTSD) with depression. ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from August 2004 to January 2008. This matter comes before the Board of Veterans' Appeals (Board) from a March 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. The Veteran thereafter moved and jurisdiction of the case was transferred to the RO in Waco, Texas. In her substantive appeal, the Veteran requested a hearing before a Veterans Law Judge. Such hearing was scheduled to take place at the RO in May 2011, but the Veteran did not report to the hearing. As the record does not contain further explanation as to why the Veteran did not report to the hearing, or any additional requests for a hearing, the Board deems the Veteran's hearing request withdrawn. See 38 C.F.R. § 20.704 (2012). The case was previously before the Board in November 2011 and June 2013, at which time the Board remanded the case for additional development. For the reasons discussed below, the Board finds that there has been substantial compliance with its prior remands. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. Prior to March 2, 2009, the Veteran's PTSD with depression was manifested by social and occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. From March 2, 2009, the Veteran's PTSD with depression has been manifested by occupation and social impairment with deficiencies in most areas, such as work, school family relations, judgment, thinking and mood. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 30 percent, but no higher, for PTSD with depression, prior to March 2, 2009, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 2. The criteria for a rating of 70 percent, but no higher, for PTSD with depression, from March 2, 2009 to February 26, 2012, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a rating greater than 70 percent for PTSD with depression, from February 27, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has met all statutory and regulatory notice and duty to assist provisions under the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran's claim concerning the proper disability ratings to be assigned to her service-connected PTSD with depression arises from her disagreement with the initial disability rating assigned to this condition following the grant of service connection. Once service connection is granted the claim is substantiated, additional 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). Therefore, no further notice as to this claim is needed under VCAA. Nevertheless, pursuant to the Board's November 2011 remand, the Veteran was provided with a December 2011 VCAA notice, which was followed by readjudication of the claim in supplemental statements of the case (SSOC). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Although the December 2011 letter only listed the TDIU claim as an issue, and not the claim for increased ratings for PTSD with depression, the letter informed the Veteran of how disability ratings are assigned, including the type and examples of evidence considered in determining the disability ratings. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Therefore the Board finds that the letter was sufficient to meet the VCAA requirements. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. Even if the letter were insufficient however, the Board finds that any error is harmless because the November 2012 SSOC set forth the relevant diagnostic codes for rating the disability on appeal. The Veteran was thus informed of what was needed not only to achieve the next-higher schedular ratings, but also to obtain all schedular ratings above the initial rating that the RO assigned. Therefore, the Board finds that the Veteran has actual notice what was necessary to achieve a higher rating for the service-connected disability at issue. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of this claim, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini, 18 Vet. App. at 120. The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, as well as her post service medical records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In June 2013, the Board remanded the Veteran's claim to obtain outstanding VA treatment records. On remand, VA treatment records dated from June 2009 to September 2009 and from November 2012 to April 2013 were obtained from the Central Texas Healthcare System in Temple, Texas and Dallas, Texas VA Medical Center. Furthermore, VA or VA fee-based psychiatric examinations have been provided to the Veteran in September 2007, February 2010, and February 2012, reflecting sufficient detail to determine the current severity of the Veteran's PTSD with depression. Each VA examiner discussed the history of the Veteran's mental condition, conducted an examination of the Veteran, and elicited information from the Veteran concerning the functional aspects of her disability. The Board therefore finds that the VA examinations obtained were adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Under these circumstances, the Board finds that the RO substantially complied with the remand directives with respect to the issue decided herein. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). 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). Service connection for depression was granted in a March 2008 rating decision, and a 10 percent initial disability rating was assigned effective February 1, 2008. Subsequently, in a June 2012 rating decision, the RO recharacterized the Veteran's psychiatric disability as PTSD with depression and increased the rating to 70 percent effective February 27, 2012. The Veteran's service-connected PTSD with depression is currently evaluated under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411. Ratings are assigned according to the degree of occupational and social impairment resulting from manifestations of the disability at issue. However, the use of the term "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 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). Under the provisions for rating psychiatric disorders, a 10 percent disability rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 30 percent disability rating is warranted 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). Id. A 50 percent disability rating requires evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when 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.). Id. A 100 percent rating is warranted when 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. Id. The Board notes that the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the 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 DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, 16 Vet. App. 436. Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). While not determinative, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). According to DSM-IV, a GAF score ranging from 31-40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A GAF score of 41-50 reflects 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). GAF score of 51-60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61-70 denotes some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 71-80 indicates that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). Prior to March 2, 2009 The Veteran underwent a VA fee-based psychiatric examination in September 2007. The examiner indicated that the claims file was reviewed. The Veteran related that she was stressed about her job and people she was working with, and she did not like being in the Army any more. She was experiencing depression about a sexual assault. She said she was depressed most of the time and had difficulty sleeping averaging four hours of sleep, having a psychomotor agitation with irritability, occasional difficulty with concentrating, fatigue and loss of energy. The Veteran had a child who stayed with her parents while he was getting out of the Army. She cooked, paid bills, did laundry, and cleaned. She went out to movies, shopping, and bowling or to eat with friends. These friends went out to eat to her house or to their houses about once a week. On mental status examination, the examiner stated that there was no impairment in her thought process or ability to communicate. There was also no history or evidence of hallucination, delusion, abnormal behaviors, or impulsive behaviors. The Veteran denied suicidal or homicidal thoughts, and maintained good personal hygiene with daily bathing and grooming. She was fully oriented, and her long-term and short-term memory was good. The examiner noted some obsessive behaviors such as washing hands frequently but noted this did not interfere with her daily functioning. Her speech was spontaneous, coherent, relevant, and adequately organized. There was no definite history of panic attacks although her affect appeared a little anxious. She admitted to depression. The Veteran was able to establish and maintain social relationships with friends and family and work a 40 hour work week. She was able to follow simple-to-complex instructions. She was not considered an imminent danger of harming herself. The diagnosis was depression and a GAF score was noted to be 85 to 90. The evidence prior to March 2, 2009 is limited to this one VA fee-based examination conducted in September 2007, while the Veteran was still in service. Based on the examination findings, the Board concludes that while all of the criteria for a 30 percent disability rating are not demonstrated, the evidence for and against a 30 percent rating is in equipoise. In making this determination, the Board finds that the Veteran's symptomatology resulted in more than mild and transient symptoms productive of decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. Rather, although the Veteran was generally functioning satisfactorily with routine behavior, self-care, and normal conversation, the September 2007 examinations findings are reasonably consistent with a disability picture of social and occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to the Veteran's symptoms of pervasively depressed mood, chronic sleep impairment, irritability, occasional difficulty with concentration, and loss of energy. The Veteran has complained of being depressed most of the time, nearly every day, insomnia, and loss of energy. She reported having a psychomotor agitation with irritability and occasionally having trouble maintaining concentration. Finally, she stated that she was stressed out about her job and people with whom she was working, and that she did not like being in service any more. These represent symptomatology of the type and degree contemplated for a 30 percent rating. Accordingly, applying the doctrine of the benefit of the doubt, the Board finds that an initial rating of 30 percent for PTSD with depression is warranted prior to March 2, 2009. See 38 U.S.C.A. § 5107(b) (West 2002); see also 38 C.F.R. §§ 4.3, 4.7 (2012). The Board has also considered whether an initial rating in excess of 30 percent is warranted prior to March 2, 2009; however, the Board finds that the weight of the evidence demonstrates that the criteria for the next higher 50 percent rating are not met and are not more nearly approximated than the criteria for a 30 percent rating. The Veteran's symptomatology is not consistent with a 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; impaired judgment or impaired abstract thinking. There is no report of a flattened affect. The September 2007 examiner noted that although the Veteran's affect appeared a little anxious, there was no definite history of panic attacks. The examiner found that there was no impairment in the Veteran's thought process or ability to communicate and that her long-term and short-term memory was good; her speech was spontaneous, coherent, relevant, and adequately organized. It was further noted that she was able to follow simple-to-complex instructions. The Board acknowledges that the Veteran described that she was nearly always depressed and occasionally irritable, which may represent disturbance of mood. However, overall, evidence does not demonstrate that this has resulted in occupational and social impairment with reduced reliability and productivity due to difficulty in establishing and maintaining effective work and social relationship. To that effect, the symptoms listed in the 38 C.F.R. § 4.130 are intended to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code, but it must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. See Mauerhan, 16 Vet. App. at 442. Here, the September 2007 examiner specifically noted that the Veteran was able to establish and maintain social relationships with friends and family and work a 40 hour work week. The evidence also reflects that during this period, the Veteran frequently went out to movies, shopping, and bowling or to eat with friends. Consequently, based on symptomatology that does not meet or approximate the type and degree of symptoms contemplated for a 50 percent rating, the Board finds an increased rating to that level is not warranted prior to March 2, 2009. From March 2, 2009 A March 2009 VA medical document noted diagnoses of panic disorder and insomnia. The Veteran received individual and group therapy from June to September 2009 to help cope with feelings of depression related to the alleged sexual trauma. In a June 2009 VA nursing evaluation note, the Veteran was fully oriented. She denied suicidal ideation. Her behavior and mood appeared appropriate and her speech was clear. In her June 2009 notice of disagreement, the Veteran reported that she had been experiencing lack of sleep for the past month due to nightmares about her sexual trauma while serving on active duty. The Veteran was provided a VA mental examination in February 2010. The VA examiner indicated that the claims file was reviewed. The Veteran related that since discharge from service in January 2008, she went to a cooking school for one year and graduated; she was not able to work as a chef due to her foot condition. She was currently a full time student at a college and reported dropping out of two of her classes because "I wasn't in the mood to do anything." She reported low motivation to do her school work or attend classes, difficulty getting along with her classmates, and getting irritated very easily. Regarding social functioning, she reported that she did not have any friends because she did not trust people. The Veteran reported that her problems were frequent and moderate. She stated that since her previous C&P examination in September 2007, she had been feeling sadder, crying more and feeling more isolated and alone. She reported that she currently slept about 4 hours per night and had problems falling and staying asleep. She felt down daily and irritable 3 to 4 times a week. She was not taking any psychotropic medications. The Veteran complained that she did not want to be around her family or friends and she did not do anything or go out. She felt sad all the time. On mental status examination, the Veteran denied any difficulty in processing information and her thought process and content were goal-directed and logical. There was no evidence of impairment of thought process or communication, delusions, hallucinations, inappropriate behavior, suicidal or homicidal ideation, obsessive or ritualistic behaviors interfering with routine activities, panic attacks, and impaired impulse control. She was able to maintain minimal personal hygiene and other basic activities of daily living. She was alert and fully oriented. She reported some problem with short-term memory but no long-term memory problems. Her speech was clear and understandable. The Veteran was competent to manage all VA funds. The diagnosis was dysthymic disorder, and a GAF score of 58 was listed. The examiner noted that the dysthymic disorder caused her intense personal distress and her depressed mood, low energy, irritability, crying spells and problems sleeping likely caused her difficulty with occupational, interpersonal and social functioning. The examiner found that the Veteran's mental disorder signs and symptoms resulted in deficiencies in most of the following areas: work, school, family relations, judgment, thinking and mood. A December 2011 VA psychology consultation report stated that the Veteran presented for the first time on referral from primary care. She related that she was having nightmares and social discomfort secondary to military sexual trauma and that she quit her job due to these symptoms. The Veteran was adequately groomed and dressed, alert and fully oriented. Her mood was euthymic and her affect was congruent to the mood. Her presentation was logical and goal-directed, with no evidence of disturbance in formal thought processes. There was no evidence of psychosis. She denied suicidal/homicidal ideation, plan or intent. The assessment was PTSD by history on Axis I, and a GAF score of 55 was listed. The Veteran was provided a VA mental examination in February 2012. The VA examiner indicated that the claims file was reviewed. The diagnoses were PTSD and depressive disorder, not otherwise specified, and a GAF score of 53 was listed. The Veteran related that she had noticed some remission in PTSD-related symptoms between 2009 and 2011 but these symptoms re-emerged following a contact she received from the alleged perpetrator of her military sexual assault. The examiner stated that the Veteran's loss of interest, sleep difficulties, irritability, isolative behaviors, and concentration difficulties are symptoms of both PTSD and depression and cannot be delineated to one diagnosis versus the other without speculation. The examiner also noted that depressive disorder, not otherwise specified, appeared to be secondary to PTSD, and the Veteran's symptoms of depressed mood and motivational difficulties appeared to be attributable to depressive disorder. The examiner found that there was occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. As to social relationships, the Veteran reported that she was single, with a son, and her relationship with her son was good; she did not have a relationship with her parents or sisters at all. She stated "I don't do friends. ... I'm at home most of the time; I'll be entertained by my fish a lot of the time; I'll watch tv sometimes." As to occupational functioning, the Veteran was currently enrolled as a full-time student. She stated that she did not get along with students very well and "they all think that I have a bad attitude because I don't want to talk to anyone." She was currently unemployed but indicated that she worked part time between 2009 and 2011. She related that she struggled with that job because she had to be a people person and she did not get along with people. The Veteran endorsed symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. She further reported symptoms of irritability, depression, difficulty falling asleep, nightmares, loss of interest, avoidance of relationships, and inability to trust people. She was found capable of managing her financial affairs. Under the PTSD diagnostic criteria, the Veteran reported symptoms of recurrent and distressing recollection of the trauma; recurrent distressing dreams of the trauma; acting or feeling as if the trauma is recurring; intense psychological distress at exposure to trauma-related stimuli; physiological reactivity on exposure to trauma-related stimuli; efforts to avoid thoughts, feelings or conversations associated with trauma; efforts to avoid activities, places or people that arouse recollection of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; restricted range of affects; difficulty falling and staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. As for her mental disability's effect on the Veteran's employability, the examiner opined that based on the Veteran's current level of functioning, her mental health-related symptoms appeared less likely as not (less than 50/50 probability) to render her unemployable. Concerning this, the Veteran reported that over the previous year, she had been a full-time college student and missed approximately one day per week of school. She reported problems of difficulty getting along with other people due to anger and depression. However, the VA examiner noted that while the Veteran's predominant difficulty involved her irritability and socialization with co-workers and customers when previously employed, she appeared capable of employment with limited interaction with staff and/or customers, if applicable. Based on a thorough review of all of the evidence from March 2, 2009, as outlined above, the Board finds that the Veteran's total disability picture most closely approximates the criteria for a 70 percent disability rating. 38 C.F.R. § 4.7 (2012). In reaching this determination, the Board finds it significant that the February 2010 and February 2012 VA examiners, who conducted a comprehensive psychiatric assessment of the Veteran, diagnosed PTSD, and provided overall assessments that the Veteran's psychiatric symptomatology resulted in deficiencies in most of the following areas: work, school, family relations, judgment, thinking and mood. This is essentially a restatement of the criteria for a 70 percent rating. Furthermore, the Veteran's symptomatology of pervasively depressed mood, crying spells, anxiety, anger, irritability, nightmares, chronic sleep impairment, low motivation, loss of interest, low energy, feeling of detachment or estrangement from others, hypervigilance, concentration disturbance, exaggerated startle response, avoidance behaviors, and social isolation, are compatible with this finding. However, the Veteran's total disability picture does not rise to the severity required for a 100 percent rating. In this regard, the Board finds that total social and occupational impairment has not been shown in this case. At the February 2012 VA examination, the Veteran stated that she maintained a good relationship with her son. Additionally, although the Veteran reported problems getting along with other people due to anger and depression, throughout the record she has been shown to have been able to finish her one year cooking school and attend college full time. She also reported working part time between 2009 and 2011. Although she struggled with the job because she had to be a people person and she was not, she was able to maintain employment for about 2 years. In this regard, the February 2012 VA examiner opined that while the Veteran's predominant difficulty involved her irritability and socialization with coworkers and customer when previously employed, she appeared capable of employment with limited interaction with staff and/or customers. Accordingly, while the Veteran has shown significant difficulty in social and occupational relationships, she has also demonstrated that she is able to establish and maintain some social and occupational relationships. Further, the February 2010 and February 2012 VA examiners found no total occupational and social impairment due to PTSD signs and symptoms. Rather, both the VA examiners opined that the Veteran's level of social and occupational functioning was best summarized as occupational and social impairment, with deficiencies in most areas, such as judgment, thinking, family relations, and mood, which is consistent with the other medical evidence of record as well as the lay testimony from the Veteran. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In this case, the credible lay and medical evidence does not demonstrate gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, or disorientation to time and place. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran has shown be alert and fully oriented, with clear and understandable speech and goal-directed and logical thought process, and her behaviors were noted as appropriate at all of her VA examinations and VA treatment sessions. The record is devoid of evidence indicating that the Veteran has had any episode of violence or active aggression. At the VA examinations, she was appropriately dressed and groomed. The February 2010 VA examination reflects she had low motivation, but the examiner indicated that the Veteran was able to maintain minimal personal hygiene and other basic activities of daily living. On mental status examinations, no suicidal or homicidal ideation, impairment in thought process or communication, impaired impulse control, obsessional or ritualistic behaviors, hallucinations, delusions, or psychosis were shown. As such, the evidence does not support a finding of total occupational and social impairment that is the criteria for a 100 percent rating for PTSD with depression. Accordingly, considering evidence in totality, the Board finds that the Veteran's disability picture more nearly approximates the criteria for the 70 percent disability rating, and therefore the 70 percent rating is the appropriate rating from March 2, 2009. 38 C.F.R. § 4.7. The issue has been reviewed with consideration of whether staged ratings would be warranted. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD with depression, there is no evidence of record that would warrant ratings in excess of those assigned herein for her PTSD with depression during the rating periods on appeal. See Fenderson, 12 Vet. App. at 126. 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 schedular ratings in this case are adequate. The diagnostic criteria contemplate and adequately describe the symptomatology of the Veteran's service-connected PTSD with depression. See Thun, 22 Vet. App. at 115. The Veteran's PTSD with depression is evaluated by the rating criteria which specifically contemplate the level of occupational and social impairment caused by this disability. See 38 C.F.R. § 4.130, Diagnostic Code 9411. When comparing the Veteran's psychiatric symptoms and social and occupational impairment with the schedular criteria, the Board finds that her symptoms are congruent with the disability picture represented by the ratings assigned herein and she does not have symptoms associated with this disability that have been unaccounted for by the schedular ratings assigned herein. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Accordingly, a comparison of the Veteran's symptoms and functional impairments resulting from her psychiatric disability with the pertinent schedular criteria does not show that her service-connected PTSD with depression presents "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Consequently, the Board finds that the available schedular ratings are adequate to rate the Veteran's PTSD with depression. Based on this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). As such, referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. The Board denied entitlement to a total disability rating based on individual unemployability (TDIU) in June 2013 and no evidence since then reasonably raises the issue of entitlement to TDIU. Therefore, the Board will not address TDIU in this decision. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Entitlement to an initial rating of 30 percent, but no higher, for PTSD with depression, prior to March 2, 2009, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating of 70 percent, but no higher, for PTSD with depression, from March 2, 2009 to February 26, 2012, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating greater than 70 percent for PTSD with depression, from February 27, 2012, is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs