Citation Nr: 1339593 Decision Date: 12/02/13 Archive Date: 12/18/13 DOCKET NO. 06-01 695 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder. 2. Entitlement to a total disability rating based on individual unemployability for the period prior to April 23, 2012. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Sara Schinnerer, Counsel INTRODUCTION The Veteran served on active duty from June 1967 to May 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office in Waco, Texas (RO), which continued the Veteran's 50 percent disability rating for posttraumatic stress disorder (PTSD). In a December 2008 decision, the Board denied the Veteran's claim for an increased rating for his service-connected PTSD. The Veteran then appealed to the United States Court of Appeals for Veterans Claims (Court). In March 2011, the Court issued a memorandum decision, wherein it vacated that part of the Board's December 2008 decision that denied a rating in excess of 50 percent for PTSD. The Court then remanded this issue for further appellate consideration in accordance with the March 2011 memorandum decision, to include the development of the claim of entitlement to a total disability rating based upon individual unemployability (TDIU), which the Court determined was raised by the record. During the pendency of this appeal, in a December 2012 rating decision, the RO granted service connection for prostate cancer associated with herbicide exposure and assigned a 100 percent evaluation, effective April 23, 2012. As such, the Veteran's combined rating has remained 100 percent since April 23, 2012. Accordingly, the Board's review of the issue of entitlement to a TDIU will be limited to the period prior to April 23, 2012. Therefore, such issue on the title page of this decision has been amended to reflect these facts. The issue of entitlement to a TDIU for the period prior to April 23, 2012 is remanded to the RO via the Appeals Management Center in Washington, DC. FINDING OF FACT During the pendency of the appeal, the Veteran's PTSD has been, and is currently manifested by a well-groomed and appropriately dressed appearance; appropriate interaction and behavior with good eye contact; no panic attacks; no hallucinations; no delusions; no thought disorder; no impairment of communication; no impairment of judgment; no impairment of impulse control; no suicidal ideation or plan; no homicidal ideation or plan; no obsessive or ritualistic behavior; the ability to carry out activities of daily living; a short temper; feelings of depression and irritability; sleep disturbance; intrusive thoughts; anxiety; nightmares; mild memory loss; dysphoric mood; blunted and depressed affect; hypervigilence; exaggerated startle; reduced appetite; avoidance behavior; re-experiencing symptoms; and arousal symptoms; all of which result in no more than reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships that results in occupational and social impairment. CONCLUSION OF LAW The criteria for a disability rating greater than 50 percent for PTSD 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 FINDING AND CONCLUSION With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). The RO's September 2004 letter to the Veteran satisfied the duty to notify provisions relating to the Veteran's claim at issue herein. 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). 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 his claim, including the opportunity to present pertinent evidence. Additionally, the September 2004 letter to the Veteran notified him that he must submit, or request that VA obtain, evidence of the worsening of his disabilities and the different types of evidence available to substantiate his claim for a higher rating. The February 2005 rating decision explained the criteria for the next higher disability rating available for the service-connected PTSD under the applicable diagnostic code. The May 2005 statement of the case provided the Veteran with the applicable regulations relating to disability ratings for his service-connected PTSD, as well as the requirements for an extraschedular rating under 38 C.F.R. § 3.321(b) and stated that, pursuant to 38 C.F.R. § 4.10, disability evaluations center on the ability of the body or system in question to function in daily life, with specific reference to employment. Moreover, the RO's March 2006 letter to the Veteran notified him of the requirements to obtain a higher rating, as well as the effective date provisions that are pertinent to the instant claim. Thus, the Board finds that the content requirements of the notice VA is to provide have been met and no further development is required regarding the duty to notify. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The duty to assist the Veteran has been satisfied in this case. The RO has obtained the Veteran's service treatment records, as well as his VA outpatient treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Moreover, the Veteran has been afforded VA examinations that are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Specifically, the October 2004, March 2006, November 2006, and April 2012 VA examiners took into account the Veteran's statements and treatment records, which allowed for a fully-informed evaluation of the PTSD. Id. In compliance with the Board's November 2011 remand, the aforementioned April 2012 VA examination was obtained to ascertain the current severity of the Veteran's PTSD. Based on the foregoing, the Board concludes that there has been substantial compliance with the November 2011 and June 2013 remand directives with respect to the issue decided herein. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As such, there is no indication in the record that additional evidence relevant to the issue being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. Indeed, in a July 2013 letter, the RO requested that the Veteran identify any additional pertinent evidence in support of his claim; however, the Veteran failed to respond to such request. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. 473 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2013). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). 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 (2013); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Service connection was granted for PTSD by a rating decision dated in July 2003 and a disability rating of 50 percent was assigned thereto, effective from April 22, 2003. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In August 2004, the Veteran initiated the current claim seeking entitlement to an increased rating for his service-connected PTSD. By a February 2005 rating decision, the RO continued the 50 percent rating for the Veteran's service-connected PTSD. PTSD is rated at 50 percent when the evidence shows 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, such as, retention of only highly learned material, forgetting to complete task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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; and the inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, to include maintenance of minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 81-90 denotes absent or minimal symptoms or good functioning in all areas. DSM-IV. A GAF score of 71-80 denotes no more than slight impairment in social functioning, with transient and expectable reactions to psychological stressors. Id. A GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. Id. A GAF score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. Id. A GAF score of 41-50 is assigned where there are, "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)." Id. A GAF of 31-40 is defined as exhibiting some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or any major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g. a depressed man that avoids friends, neglects family, and is unable to work; a child that frequently beats up younger children, is defiant at home, and is failing at school). Id. In October 2004, the Veteran underwent a VA examination, during which he reported that he had trouble sleeping and felt depressed and irritable because he could not get along with others. He reported that he had a short temper. He stated that he retired from his job as a salesman in September 2003, after 29 years, because of increased conflicts with customers. He reported that he experienced only two hours of restful sleep a night and infrequent, once or twice a week or sometimes twice a month, nightmares and dreams about his Vietnam experiences. He reported that his wife of 36 years was very supportive. He indicated that he was in close contact and a good family relationship with his three grown children. He stated that he did not socialize except when attending occasional Veterans of Foreign Wars meetings, or if he went to church with his wife. He reported that his leisure pursuits were fishing and gardening. On examination, the Veteran was adequately dressed in casual attire. He had appropriate interaction with good eye contact. The Veteran showed no impairment of thought process or communication, no delusions or hallucinations, and no suicidal or homicidal ideation or plan. He was fully oriented to time, person, and place. His speech was coherent and relevant with no evidence of obscure speech patterns. His memory was intact. He did not demonstrate obsessive or ritualistic behavior. There was no evidence of panic attacks or impaired impulse control, nor did he report such. The Veteran's GAF score was 50. The diagnosis was chronic PTSD. VA outpatient treatment records dated in October 2005 show that the Veteran reported difficulty sleeping. He also reported that felt on edge most of the time. He stated that he experienced anxiety attacks. He denied suicidal thoughts. He reported that he had been married to his wife for 37 years, but explained that recently, there was a conflict in their relationship. He stated that he tried to avoid large crowds of people, which made him very nervous, and caused him to experience a lot of intrusive thoughts. Examination of the Veteran revealed normal speech, logical and goal directed thought process, and no hallucinations, delusions, or suicidal or homicidal ideation. The assessment was PTSD. In March 2006, the Veteran underwent a VA examination, during which he reported that he had difficulty with his memory. He stated that he slept well, controlled his irritability, and improved his relationship with his wife. He also reported that he and his wife had worked hard to make their relationship supportive. He reported that he did not have any friends, but enjoyed gardening. He denied problems with anxiety. He stated that he had intrusive memories, but denied any current nightmares. He reported that he experienced constant hypervigilance and exaggerated startle response. He reported that he had a lack of motivation and a lessened ability to derive pleasure from previously enjoyed activities. He reported that he left his employment two and a half years ago due to his inability to get along with certain personnel. On examination, the Veteran was casually dressed. He was alert and oriented to time, person, and place. His mood was dysphoric and his affect was somewhat blunted, as well as depressed. There was no evidence of suicidal or homicidal ideation, hallucinations, or delusions. His thought processes were generally logical and goal directed. His judgment was grossly intact. There was no evidence or report of panic attacks, obsessive or ritualistic behavior, or impaired impulse control. There was evidence of recent and remote recall per the Veteran's report, but his overall intellectual functioning was in the average range. His insight appeared limited. He denied sleep disturbance, but reported a reduced appetite, hypervigilence, and exaggerated startle. The Veteran's GAF score was 50. Upon review of the claims file, the examiner diagnosed PTSD, with minimal reported symptoms. VA outpatient treatment records dated in May 2006 through June 2009 demonstrate that the Veteran attended a monthly support group for his PTSD. In November 2006, the Veteran underwent a VA examination, during which he reported that he had feelings of depression and experienced trouble sleeping. He further reported that he isolated himself from others. He stated that he worked as a salesman for 29 years, but took an early retirement because he had difficulty getting along with customers and staff members. He reported that he had been married to his wife for 34 years, and explained that she was his sole support. He stated that he had contact with his three adult children, but characterized the relationship as distant. He further reported that he had infrequent contact with his eldest son because he had difficulty getting along with him. He reported that he was very close to his grandson. He indicated that he did not have social contacts outside of his family, and explained that he felt easily aggravated by other people, and avoided them for that reason. He reported that he rarely participated in activities with organizations to which he belonged. His stated that he participated in fishing and gardening. He indicated that he no longer drank alcohol and recently quit smoking. On examination, the Veteran was well-groomed and appropriately dressed. He was oriented to time, person, and place. He maintained eye contact during the interview and displayed appropriate behavior. His mood was euthymic and he displayed affect consistent with his self report. His speech rate and volume were within normal limits. His thought processes were logical, coherent, and goal-directed. There was no indication of psychotic symptoms, and no suicidal or homicidal ideation, intent, or plan. He reported short term memory loss, to include forgetting names and misplacing items; however, he was able to recall the details from his military experience and appeared to be a reliable historian. The Veteran's GAF score was 50. Upon review of the claims file, the examiner diagnosed PTSD. The examiner remarked that the Veteran reported avoidance, re-experiencing, and arousal symptoms consistent with PTSD, but was vague in describing these symptoms. The examiner also noted that Veteran's continued symptoms of hypervigilence. The examiner stated that the Veteran's PTSD symptoms had impeded his ability to sustain employment and form relationships outside of his immediate family. An April 2009 VA outpatient treatment record demonstrates that the Veteran reported that he struggled with sleep issues and mild irritability. He denied suicidal and homicidal ideation. A February 2010 VA outpatient treatment record demonstrates that the Veteran retired several years previously, but it was a "forced retirement." He denied having any problematic relationships. He also denied suicidal ideation. He reported that he was married and had three adult children, as well as several siblings. He stated that he and his wife were involved in church activities. The examiner noted that the Veteran continued to express symptoms of PTSD. In April 2012, the Veteran underwent a VA examination, during which he reported that he was still married to the same woman with close family ties. He stated that he had seven grandchildren, as well as good relationships with his grown children. He noted that he saw some of his children and grandchildren once a month or so, and others less due to the distance. He stated that he was retired since 2004. He reported sleep disturbance, but explained that some disturbance was due to his knee aching. He indicated that he took prescribed medication since 2002 for his sleep disturbance. On examination, there was evidence of depressed mood and chronic sleep impairment. There was evidence of mild memory loss, such as forgetting names, directions, or recalling events, but no impairment of short or long term memory, such as forgetting to complete tasks. There was evidence of difficulty in establishing and maintaining effective work and social relationships. There was no evidence of inappropriate behavior, neglect of appearance, disorientation to time or place, panic attacks, anxiety, impaired judgment, impaired thought processes, illogical speech, impaired communication, or impaired impulse control. There was no evidence of suicidal or homicidal ideation, obsessive rituals, delusions, or hallucinations. There was no evidence of the inability to carry out activities of daily living. The Veteran's GAF score was 60. The examiner noted that the claims file was not available, but explained that the November 2006 VA examination report had been reviewed. The examiner found that the Veteran did not meet the full criteria for PTSD at the time. The examiner remarked that the Veteran's main symptoms were sleep disturbance and irritable mood, and noted that per the Veteran's report, some of his sleep disturbance was the result of his aching knee. The examiner noted that the Veteran was retired, but kept busy around the house, to include engaging in gardening and cooking. The examiner noted that the Veteran went to the gym and attended church regularly. The examiner stated that the Veteran had a close relationship with his wife and family. The examiner indicated that that while the Veteran was not seeking employment, if he did so, his PTSD symptoms would probably interfere with work efficiency, and he would need to find a job that did not require much interaction with the public due to his irritable mood. In July 2012, the April 2012 VA examiner reviewed the Veteran's claims file. The examiner reiterated the Veteran's GAF score of 60, and noted that while the Veteran complained of some symptoms that could be attributed to PTSD, he did not meet the full criteria for PTSD at that time. The examiner reiterated that if the Veteran was to seek employment, his PTSD symptoms would probably interfere with work efficiency, and he would need to find a job that did not require much interaction with the public due to his irritable mood. The examiner stated that the Veteran did not meet the criteria for a DSM-IV diagnosis of any type of mood disorder. During the rating period on appeal, the Veteran's GAF scores were 50 in 2004, 50 50 in 2006, and 60 in 2012, indicating moderate to serious symptoms. DSM-IV. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2013); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). The Veteran's manifestations of PTSD include a well-groomed and appropriately dressed appearance; appropriate interaction and behavior with good eye contact; no panic attacks; no hallucinations; no delusions; no thought disorder; no impairment of communication; no impairment of judgment; no impairment of impulse control; no suicidal ideation or plan; no homicidal ideation or plan; no obsessive or ritualistic behavior; the ability to carry out activities of daily living; a short temper; feelings of depression and irritability; sleep disturbance; intrusive thoughts; anxiety; nightmares; mild memory loss; dysphoric mood; blunted and depressed affect; hypervigilence; exaggerated startle; reduced appetite; avoidance behavior; re-experiencing symptoms; and arousal symptoms. The evidence of record also demonstrates that the Veteran has been married to his wife for more than 40 years. While in October 2005, the Veteran reported that he and his wife were experiencing conflict in their relationship, overall, the record shows that has a good relationship with his wife, as he described her as very supportive. Further, in March 2006, he stated that he and his wife worked hard to make their relationship supportive, and again noted her to be his support system in November 2006. Similarly, in April 2012, he noted that he was still married to the same woman, with close family ties. Moreover, in November 2006 he characterized his relationship with his three grown children as distant; however, the record demonstrates that he generally has a good relationship with his children, as he reported such during examination in October 2004 and April 2012. Further, in November 2006, he reported that he was close to his grandson. Additionally, in April 2012, he indicated that he saw some of his children and grandchildren once a month or so, and others less due to the distance. Although he reported that he did not have friendships outside of his family, he participated in a Veteran's service organization, attended church with his wife regularly, went to the gym regularly, and enjoyed gardening. Finally, the evidence shows that subsequent to discharge from service, the Veteran worked for approximately 29 years for the same company as a salesman. Although, the Veteran consistently reported that he retired early as a result of his inability to get along with others, he maintained his position for almost three decades with the same company. Accordingly, the medical evidence of record does not demonstrate that there is occupational and social impairment with deficiencies in most areas. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The GAF score of 50 assigned to the Veteran's PTSD as a result of the VA examinations in 2004 and 2006 are indicative of a severe disability picture with serious impairment in social, occupational, or school functioning, such as the inability to keep a job; or symptoms such as suicidal ideation, severe obsessional rituals, or frequent shoplifting. However, the objective and subjective symptomatology, as well as the clinical evidence reported at such examinations, do not reflect symptoms that are indicative of such a disability picture. While the examinations revealed mild memory loss, sleep disturbance, hypervigilence, dysphoric mood, blunted and depressed affect, avoidance behavior, re-experiencing symptoms, and arousal symptoms, such symptomatology is indicative of moderate impairment, as the Veteran was able to maintain a job for 29 years as a salesman with the same company, he has remained married to his wife for more than 40 years in a supportive relationship, and he has a relationship with his grown children and spends time with his grandchildren. In addition, the Veteran was well-groomed and appropriately dressed; displayed appropriate interaction and behavior with good eye contact; there were no panic attacks; there were no hallucinations, delusions, thought disorder, or impairment of communication; there was no impairment of judgment; there was no impairment of impulse control; there was no suicidal ideation or plan; there was no homicidal ideation or plan; and there was no obsessive or ritualistic behavior. Serious impairment in family relations and at work were not shown, and there was no evidence of suicidal ideation, severe obsessional rituals, or frequent shoplifting. DSM-IV. The assigned GAF score and the objective symptomatology resulting from the April 2012 VA examination presents a moderate disability picture, and connotes moderate difficulty in social or occupational functioning, suggesting that a disability picture in excess of 50 percent is not warranted. Id. Specifically, the April 2012 VA examiner indicated that there was evidence of difficulty in establishing and maintaining effective work and social relationships, suggesting the current 50 percent disability picture. Indeed, the April 2012 VA examination revealed mild memory loss, such as forgetting names, directions, or recalling events, and the examiner found that there was no short or long term memory loss. In addition such examination also revealed a depressed mood and chronic sleep impairment. Such symptoms, in fact, are suggestive of a 30 percent disability picture. Based on the totality of the evidence, including consideration of the GAF scores and the objectively and subjectively noted symptomatology, and in accordance with all applicable legal criteria, the Board finds that the Veteran's disability is appropriately evaluated as 50 percent disabling, as the effect of the Veteran's PTSD disability, results in no more than reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships that results in occupational and social impairment. 38 C.F.R. § 4.130, Diagnostic Code 9411; Carpenter, 8 Vet. App. at 242. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2013). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2013). 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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Id. at 115. If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. See VAOPGCPREC 6-96; 61 Fed. Reg. 66749 (1996) (when service-connected disability affects employment "in ways not contemplated by the rating schedule[,]" § 3.321(b)(1) is applicable). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the 50 percent rating for PTSD inadequate. The Veteran's PTSD is evaluated as a mental disability pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his disability. Id. As noted above, the Veteran submitted evidence demonstrating that his most recent GAF assessments resulted in scores of 50 and 60. However, "[a]lthough certain symptoms must be present in order to establish the diagnosis of PTSD . . . it is not the symptoms, but their effects, that determine the level of impairment." See Mauerhan, 16 Vet. App. 436, 443 (2002) (citing 61 Fed. Reg. 52,695, 52,697 (1996) (holding that § 4.130 "'is a reasonable and permissible construction of 38 U.S.C. § 1155 '"). As demonstrated by the evidence of record, the Veteran's PTSD is marked by a well-groomed and appropriately dressed appearance; appropriate interaction and behavior with good eye contact; no panic attacks; no hallucinations; no delusions; no thought disorder; no impairment of communication; no impairment of judgment; no impairment of impulse control; no suicidal ideation or plan; no homicidal ideation or plan; no obsessive or ritualistic behavior; and the ability to carry out activities of daily living; a short temper; feelings of depression and irritability; sleep disturbance; intrusive thoughts; anxiety; nightmares; mild memory loss; dysphoric mood; blunted and depressed affect; hypervigilence; exaggerated startle; reduced appetite; avoidance behavior; re-experiencing symptoms; and arousal symptoms. The evidence of record also demonstrates that, after his retirement from the military, the Veteran worked for approximately 29 years as a salesman for the same company. The evidence of record also demonstrates that the Veteran has been married to his spouse for more than 40 years. Moreover, the Veteran has good familial relationships. The Veteran also participates in social and civic activities. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by a 50 percent disability rating for PTSD. A rating in excess of 50 percent is provided for certain manifestations of PTSD, but the medical evidence demonstrates that those manifestations are not present in this case. The criteria for a 50 percent rating reasonably describe the Veteran's disability level and symptomatology and, therefore, a schedular evaluation is adequate and no referral is required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOPGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Thus, based on the evidence of record, the Board finds that the Veteran's disability picture cannot be characterized as an exceptional case, so as to render the schedular evaluations inadequate. The threshold determination for a referral for extraschedular consideration was not met and, consequently, the Board finds that the Veteran is not entitled to referral for an extraschedular rating. Thun, 22 Vet. App. at 115. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no distinct periods of time during the appeal period, when the Veteran's service-connected PTSD varied to such an extent that a rating greater or less than 50 percent would be warranted. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Finally, in reaching this decision, the Board considered the doctrine of reasonable doubt. However, as discussed above, as the preponderance of the evidence is against a rating in excess of 50 percent for the Veteran's PTSD at any time during the appeal period, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A disability rating in excess of 50 percent for PTSD is denied. REMAND Regarding the Veteran's claim of entitlement to a TDIU for the period prior to April 23, 2012, the RO denied the claim because the Veteran did not meet the scheduler criteria for TDIU of 38 C.F.R. § 4.16(a) (2013). In this regard, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, must submit to the Director, VA Compensation and Pension Service, for extraschedular consideration in all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards. 38 C.F.R. § 4.16(b). With respect to the claim for TDIU on an extraschedular basis, the October 2004 VA examiner confirmed the Veteran's diagnosis of PTSD, and noted the Veteran's report of leaving his job as a salesman in September 2003, after 29 years, because of increased conflicts with customers. In addition, during the March 2006 VA examination, the Veteran reported that he retired because of his inability to get along with others, to include personnel. Further, the November 2006 VA examiner noted that the Veteran's PTSD symptoms impeded his ability to sustain employment. In addition, the April 2012 VA examiner noted that if the Veteran was seeking employment, his PTSD symptoms would probably interfere with work efficiency, and he would need to find a job that did not require much interaction with the public due to his irritable mood. In this regard, the Board notes that the Veteran's career of 29 years was centered around his ability to interact with the public, as he was a salesman. As such, there is evidence to suggest that the Veteran was unable to secure and follow a substantially gainful occupation due to his service-connected PTSD for the period prior to April 23, 2012. Accordingly, the Board finds that referral of the Veteran's claim to the Director, VA Compensation and Pension Service, is warranted. The Board lacks the authority to assign an extraschedular rating in the first instance. See Floyd v. Brown, 9 Vet. App. 88 (1996). Accordingly, the case is remanded for the following actions: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim for entitlement to a TDIU for the period prior to April 23, 2012. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims file by the RO. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. If the RO is unable to secure any of the identified records, the RO must notify the Veteran and his representative and (a) identify the information the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain that information; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that the Veteran is ultimately responsible for providing information. The Veteran and his representative must then be given an opportunity to respond. 2. The RO must refer the claim to the Director, Compensation and Pension, for a determination as to whether the Veteran is entitled a TDIU prior to April 23, 2012, as per 38 C.F.R. § 4.16(b). The RO must include in this referral a full statement as to the Veteran's service-connected disabilities, employment history, education, and vocational attainment and all other factors having a bearing on the issue. The Director, VA Compensation and Pension, is requested to provide adequate reasons and bases for any decision. The report must be typed. 3. After completing the above actions, the RO must readjudicate the Veteran's claim, taking into consideration any and all evidence that has been added to the record since its last adjudicative action. If the benefit on appeal remains denied, the Veteran and his representative must be provided a supplemental statement of the case and given an appropriate opportunity to respond. Thereafter, the case must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs