Citation Nr: 1342922 Decision Date: 12/26/13 Archive Date: 01/07/14 DOCKET NO. 08-08 409 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a left wrist disability. 2. Entitlement to an initial disability evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from July 1982 to November 1998. These matters come before the Board of Veterans' Appeals (Board) from a May 2007 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Roanoke, Virginia. During the pendency of the Veteran's claim, the RO in a July 2012 rating decision, granted the Veteran a 70 percent initial rating for his PTSD. These matters were previously before the Board in August 2011 and were remanded for further development. They have now returned to the Board for further appellate consideration. FINDINGS OF FACT 1. The most probative evidence of record is against a finding that the Veteran has a left wrist disability causally related to, or aggravated by, active service. 2. Throughout the rating period on appeal, the Veteran's PTSD has been manifested by complaints of depression, anxiety, irritability, exaggerated startle reflex, and sleep disturbances, with continued evidence that he has personal relationships, can live and function independently, has been employed, and has an assignment of a GAF score of at least 50, demonstrating that his symptoms do not cause total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for a left wrist disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2013). 2. The criteria for an evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided in February 2007. In addition, the rating issue on appeal stems from the Veteran's disagreement with an initial evaluation following the grant of service connection for PTSD. 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). VA has a duty to assist the appellant in the development of the claims. The claims file includes service treatment records (STRs), post service medical records, and the statements of the Veteran in support of the claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim for which VA has a duty to obtain. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that adequate examinations/opinions have been obtained. The claims file includes VA examination reports from 2011. The reports include clinical examination findings, diagnostic testing, and the Veteran's reported symptoms. The left wrist disability report provides an adequate rationale for the clinician's opinion based on evidence of record. The PTSD report provides findings relevant to the criteria for rating the disability. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008), Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Rating Disabilities in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Specific schedular criteria for rating mental disorders PTSD is rated by applying the criteria in 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (2013). The VA Schedule rating formula for mental disorders reads in pertinent part as follows: 100 percent rating (the maximum schedular rating) - 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. 70 percent - 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. 50 percent -- 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. 30 percent-- 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). 10 percent -- 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. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Global Assessment of Functioning (GAF) GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). According to the pertinent sections of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV), a GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions so psychosocial stressors and there is no more than slight impairment in social, occupational, or school functioning. A GAF score of 61 to 70 indicates some mild symptoms or some difficulty social occupational or school functioning but that an examinee is generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. A GAF score of 31 to 40 indicates that the examinee has some impairment in reality testing or communication such as speech is illogical, obscure, or irrelevant, or that the examinee has major impairment in several areas. See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). Analysis The Board has reviewed all of the evidence in the Veteran's claim file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Left Wrist Disability The Veteran avers that he has a left wrist disability due to active service. An essential element of a claim for service connection is evidence of a current disability. A September 2011 VA examination reflects a diagnosis of a left wrist strain. A strain is defined as overstretching or overexertion of some part of the musculature. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (31st Ed. 2007). A second element of a claim for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. The STRs reflect that in October 1997, the Veteran was initially seen for a report of right wrist pain when doing pull ups. The subsequent notation, written in different handwriting and with a different signature, reflects that it was the Veteran's left wrist that hurt when doing pull ups. The Veteran had a full range of motion with mild crepitus noted. He had no edema, no ecchymosis, and no bulging. He could touch all his fingers to his thumb. He was assessed with left ulnar tendon/muscle strain. He was prescribed no pull-ups for 14 days and Motrin. He was to return to the clinic in two weeks if the pain reoccurred. The Veteran served for another 13 months of active duty; however, there are no further records of complaints of left wrist pain. Notable, a July 1998 Report of Medical Examination for separation (ETS) purposes reflects that the Veteran had right wrist pain. An August 1998 clinical record reflects that the Veteran had complaints of recurrent right wrist pain, and an x-ray was taken of the right wrist. In November 1998, the Veteran again had complaints of right wrist pain. Thus, while the evidence may support a finding that the Veteran had left wrist pain in October 1997, it does not support a finding that the Veteran had continued complaints of, or treatment for, left wrist symptoms. Thus, the Board finds that any pain in October 1997 was acute and transitory as the STRs are negative for any follow-up treatment. The Board acknowledges that the absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of appellant's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). See also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) However, in the present case, not only is there a lack of clinical records noting left wrist complaints, but the clinical records in evidence specifically reflect that the Veteran had complaints with regard to the right wrist. The Board finds that if the Veteran had left wrist complaints, it would have been reasonable for him to have reported them, and for it to be noted in the claims file, when he sought treatment for his right wrist. The Board also notes that the Veteran reported to the 2011 VA examiner that he injured his left wrist in service in 1990 or 1991 when he jumped off a truck. The Veteran stated that he suffered a "really bad strain of the left wrist" at that time. The Board acknowledges that the Veteran is competent to testify as to pain; however, the Board finds that he has not been shown to have the experience, education, and training necessary to diagnose a "really bad strain" with chronic pain. In addition, even if the Veteran is competent to testify as to such, the Board finds that any such statement is outweighed given the record as a whole. The Veteran's January 1992 report of medical history for a routine physical reflects that the Veteran did not have any complaints with regard to the wrist, and the report of medical examination reflects normal upper extremities. As the Veteran reports that he was injured in 1990 or 1991, it is reasonable that if he had any chronic pain, it would have been noted in 1992; it is not. Moreover, there is no evidence that the Veteran was given a physical profile to refrain from push-ups or pull-ups prior to the 1997 incident. Profiles dated in 1996 are with regard to running and a ruptured Achilles tendon. The Veteran's STRs include complaints of low back pain, leg pain, sinus pain, urticaria, testicular pain, ruptured Achilles tendon, otitis, rash groin, stomach ache, burns, a root canal, laceration to the right index finger, hemorrhoids, and a headache with abdominal pain and shooting pain in back and down both legs; notably, there are no complaints of left wrist pain with the exception of the one notation in 1997. The Veteran separated from service in November 1998. He underwent a QTC examination in April 1999 with regard to complaints of bilateral wrist pain. Although a diagnosis of tendinitis was made for the right wrist, there was no diagnosis of a disability for the left wrist. In addition, an April 1999 x-ray showed no evidence of arthritis of the wrist. A July 2001 VA clinical record also reflects that the Veteran had slight pain with strong pressure on the lunate, and complained of slight pain with forced hyperextension of the wrist. However, the examiner found no objective findings of a left wrist disability. At that time, it was noted that the Veteran was employed as mail carrier for the postal service. A third requirement for service connection is competent credible evidence of a nexus between the current disability and the in-service disease or injury. The Board finds, for the reasons noted below, that this third requirement for service connection has not been met. The competent credible clinical evidence of record is against a finding that the Veteran has a current left wrist disability causally related to, or aggravated by, active service. The Veteran underwent a VA examination in September 2011. The examiner considered the Veteran's statement that in 1990 or 1991 that he had "suffered a really bad strain of the left wrist." The Veteran reported that he did not initially seek care for this injury, but was eventually given ibuprofen and released to regular duty. He reported that through the years, he has had pain but has not sought medical care. A radiograph of the left wrist revealed no evidence of acute fracture. The carpus was well aligned. The bone mineral density was within normal limits. No erosions were identified. In sum, the Veteran had normal radiographs of the left wrist. Upon clinical examination in 2011, the examiner found that the Veteran had tenderness and abnormal motion, but also noted that the Veteran "appears to give poor effort." The examiner diagnosed the Veteran with a left wrist strain. The examiner also stated, in pertinent part, as follows: The veteran's current left wrist disorder is less likely as not related to the veteran's active service. Rationale: the recorded episode of left wrist pain in 1997 was a mild strain for which the only required treatment was avoidance of pull ups for 14 days and use of over the counter doses of ibuprofen. An injury of this type would not be expected to result in long term problems. Subsequent military medical evaluations indicate no problems with this wrist indicating that the condition resolved. There were records from 1998 mentioning right wrist tendonitis but left wrist is not mentioned. The veteran was seen in 2001 at McGuire va for bilateral wrist pain, however, no objective abnormality was found and there is not documentation that supports this being a persistent medical issue requiring medical evaluation and treatment. Additionally, the veteran engages in manual labor occupations that put him at high risk for repetitive use injury of the wrists and this is a more plausible explanation for his ongoing condition. In sum, the STRs do not reflect chronic left wrist pain or any complaints of pain in the Veteran's last 13 months of service. Subsequent to service, the Veteran began working at a job where he contends that he had wrist pain every day. The Board finds that any statement of chronic left wrist pain since an injury or incident in service is less than credible given the record as a whole. Moreover, continuity of symptoms, as a basis for service connection, is only warranted for disabilities listed under 38 C.F.R. § 3.309. A strain is not such a disability. The Board also finds that the opinion of the examiner, a physician, who has education, training, and experience, in medical issues, is more probative than that of the Veteran. The examiner's opinion, which was based on a clinical examination, x-rays, and a review of the Veteran's medical and occupational history, is more than adequate and is probative of the issue. Based on the above, the Board finds that service connection for a left wrist disability is not warranted. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Increased Rating PTSD The Veteran is service connected for PTSD, evaluated as 70 percent disabling effective from August 2006. In order to be assigned a particular rating, a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The key element for a rating under the General Formula for Mental Disorders is the degree of social and occupational impairment caused by those symptoms. The Board notes that there are extensive clinical records in the claims file, to include numerous PTSD group therapy records which do not necessarily reflect this particular Veteran's PTSD symptoms. The Board has considered all the records in the claims file even though it has not cited to all of them below. VA records prior to the rating period on appeal have been reviewed as the Board must consider the history of the disability. The records reflect that the Veteran had a GAF score of 50. The records also reflect that the Veteran reported recurrent and vivid nightmares, intrusive thoughts, occasional flashbacks, sleep and concentration problems, periods of irritability, frustration, and anger outburst, social isolation and withdrawal, reliving of combat experiences, hyperarousal, and avoidance behavior. The Veteran reported that he rarely speaks with his children, yells all the time, and is moody. It was noted that he reported that he keeps his distance from his children, but remains married. May 2005 VA clinical records reflect that he was moody and irritable, and has been attending PTSD group therapy. It was noted that he was not suicidal. July 2005 VA clinical records reflect that the Veteran reported that he is sad that he has no friends or few people with whom he can communicate. It was further noted that he was taking Zoloft and cannot tell if it helped his mood or not. 2006 records reflect that the Veteran was having significant depression and gets into agitated states when there is a conflict in his marriage. He continued to attend PTSD group therapy. 2007 records reflect that the Veteran would be out of town because he was assisting his son with college campus visits; thus, there is evidence that he had a relationship with his son and was able to function socially. The 2007 records also reflect that he continued to attend group PTSD meetings. Correspondence dated in June 2008 from J.B., the interim Director of the H.H. McGuire Medical Center PTSD program reflects that the Veteran has been enrolled in the program for several years. It reflects that in November 2007, the Veteran voluntarily enrolled in the outpatient Substance Abuse Treatment Program (SATP), the impetus for which was an "incident" that occurred at the USPS, his employer. It was noted that the Veteran had suffered a "lapse in judgment and engaged in behavior which was out of character for him", due to drinking heavily and regularly together with a lack of sleep and in combination with several medications. The Veteran reported that several weeks prior to the incident he had been working when an electrical transformer blew near him, causing a flashback and causing him to increase his alcohol consumption. It was noted that the Veteran has individual treatment, group treatment, and several psychotropic medications. A July 2008 VA record reflects that the Veteran reported that he had a difficult weekend that resulted in exacerbation of his PTSD. He was involved in legal problems at work and was feeling increasingly anxious and paranoid. He also reported that he and his adult stepson nearly got into a physical altercation after his [stepson] made disparaging comments about him. He reported that he [the Veteran] had to be restrained by his son and that police were called. A December 2008 VA clinical record reflects that the Veteran reported nightmares and flashbacks, was anxious and depressed. He denied suicidal or homicidal ideation and he had insight. A July 2009 VA clinical record reflects that the Veteran was excited about his decision to move out of his home due to the poor relationship that he had with his wife and stepson, which was causing him a lot of anxiety. It was noted that "[o]n the other hand, he is very proud of the relationship that he has with his daughter and son. He reports that he will be on vacation for 2 weeks and looking forward to going to go to Georgia to visit with his son." It was noted that his children are his "joy and strength". A January 2010 VA clinical record reflects that the Veteran was seen for an unscheduled walk in visit. He reported that he and his wife separated a few months earlier; however, he was unsure if he had made the right decision. He noted that he remained in contact with his wife, and that since the separation, he had felt better and more relaxed. It was further noted as follows: He maintains good communication with his children and noted that both are doing [sic] in college. [The Veteran] continues to work as a letter carrier with the USPS with noted continued work-related stress and anxiety. He has been doing better in maintaining his composure. A February 2010 VA clinical record reflects that the Veteran had a GAF score of 50. He desired to return to the SATP. He reported chronic recurrent and vivid nightmares, intrusive thought, occasional flashbacks, sleep and concentration problems, periods of irritability, frustration, anger outbursts, and avoidance behavior related to his military experiences. He reported that his social networks are few and he reported a tendency to socially withdraw and isolate from others. He reported recent stressors of being accused of ripping up mail at his employment, which he stated that he did not remember. An April 2010 VA clinical record reflects that the Veteran reported that the last few months had been stressful for him but he was starting to "turn a corner". He was planning on pleading guilty to one of the six criminal charges pending against him for a work-related crime, and was positive about his future. Although he had reported suicidal ideation when the criminal charges were originally filed and as the situation worsened, he had not had suicidal ideation in "quite some time." The Veteran reported feeling apprehensive but confident about the future. The clinician noted that "[o]verall, [the Veteran's] condition remains stable despite lingering symptomatology. He denied current suicidal or homicidal ideation, intent, or plan. A November 2010 VA telephone contact note from a vocational rehabilitation specialist reflects that it was her opinion that the Veteran "is fully capable of obtaining and maintaining employment in the community. . . . [V]eteran has demonstrated by his excellent work history that he can locate competitive employment independently and maintain it." A November 2010 VA clinical record reflects that the Veteran reported that he was trying to get by, was living in an apartment, trying to start his own business, but it was not "taking off well". He was alert, oriented times four, had a dysthymic mood, depressed affect, denied current suicidal thoughts, had spontaneous, logical, and goal directed thoughts, and reported that his two children kept him going. A January 2011 record reflects that the Veteran reported that he was doing "okay" and trying to get motivated and less depressed. He reported that he was not sleeping well. He was alert, oriented times four, had a depressed mood, had a depressed affect, was not psychotic, and denied suicidal or homicidal ideas. A February 2011 VA record reflects that the Veteran was still depressed, and had been on Wellbutrin for a couple of years, with a dose increase in January 2011. It was noted that he "was involved in group therapy, which he really enjoyed; however, now group no longer meets here. Feels hopeless at times, but denies [suicidal ideation/homicidal ideation]." It was further noted that he talks to his two college kids frequently and lives by himself. He denied hallucinations, complained of insomnia, and had "no PTSD symptoms." An April 2011 VA record reflects that the Veteran reported that he was doing "okay" and trying to establish his own business but was running into difficulty due to the economy. "He reported that he has been managing his symptoms fairly well and tends to stay to himself. He seemed to benefit from the Youngs Guns group and has attended one or two of the newly transitioned post-Vietnam Veterans support groups. He expressed interest in continuing his participation as well as individual follow-up." A May 2011 VA record reflects that the Veteran had recently received a five day jail sentence because, while on probation for the above noted guilty plea, he was involved in a sting operation concerning stolen gift cards in the mail. The clinical psychologist stated that the Veteran had been "faring well with minimal problems aside from feeling the financial strain of being self-employed in today's market. His symptoms had been in check, he had remained abstinent from alcohol, and he was making adjustments to his children being in or graduating from college and living separately from his wife." A September 2011 VA examination report reflects that the Veteran had a GAF score of 55. The examiner stated that, if considering his PTSD symptoms only, his GAF score would actually be 58 and that this "reflects prominent difficulties in the areas of mood, motivation, sleep, interpersonal functioning, anxiety, intrusive thoughts and nightmares associated with his Gulf War deployment, hypervigilance and exaggerated startle, emotional detachment and some numbing, and some avoidance." The report reflects that the Veteran was living separately from his wife, had a good relationship with his two children, has telephone contact with his children nearly every day, and has a few close friends with whom he has contact approximately once per week. The Veteran reported that he does odd jobs with his landscaping business. He attended group meetings once per month. Upon clinical examination, the Veteran was generally alert and cooperative, demonstrated good grooming and hygiene, and made appropriate eye contact. His mood was depressed with congruent affect. He denied any current suicidal intent or plan; however, he endorsed intermittent and very brief passive thoughts about death and dying. A September 2011 VA clinical note reflects, in pertinent part, as follows: [the Veteran reported that] "he has been 'hanging in there, but it's getting tough.' He has been dealing with several external stressors, primarily related to familial and occupational/financial issues. He reported that he has been actively searching for stable employment but the economic situation plus having a felony charge has been interfering with this. He reported that he has had several promising interviews, only to be turned away when asked about his felony conviction. He remains on supervised probation, but has been abiding by all conditions and has been making progress. [The Veteran] also continued to operate his own lawn care business but has been stymied by the economy. He also reported continued PTSD symptoms such as hypervigilance, restlessness, poor sleep (falling asleep between 2200-2230, then waking between 0200-0205 and not being able to return to sleep), intrusive thoughts, depressed mood, anhedonia, and avoidance behavior. He has been trying to stay busy and connected to some fellow post-Vietnam Veterans from group, but continues to feel overwhelmed and disconnected. He stated that he remains close with his children and that he and his wife have been communicating better since their separation. He has been encouraged to move down to Georgia with his sister, but is reluctant to leave the area until his daughter is out of the house (junior in high school). [The Veteran] demonstrated good insight into his condition and been actively doing things to try to cope as best as circumstances will allow. He acknowledged that a lot of this is mental and that he needs to continue to keep a positive attitude and utilize some of the skills and techniques learned through the PTSD program. He also agreed to stay in close contact with the undersigned as needed. We spent most of the session discussing his current mental state, changes he has noticed, and ways to continue coping with this symptomology. Overall, his condition remains stable despite continued PTSD and depressive symptomology. He denied current suicidal or homicidal ideation, intent, or plan. A November 2011 VA clinical record reflects that the Veteran reported that he continues to have "difficulty sleeping (maximum four hours per night), intrusive thoughts, and frequent anxiety with panic attacks. He reported that he often interprets his anxiety as 'something wrong with me physically like with my heart' and will occasionally seek medical help. He sometimes utilizes the relaxation skills and techniques taught in the program and these seem to be effective." He reported that he recently started working on a contract painting apartments in Northern Virginia at night. He reported that he remains close to his two children and they are good social supports for him. It was noted that the Veteran continues to abide by the terms of his federal probation, and continues to demonstrate good insight into his condition. The examiner stated that "[o]verall, his condition remains stable despite continued PTSD and depressive symptomology. He denied current suicidal or homicidal ideation, intent, or plan." A January 2012 VA clinical record reflects that the Veteran had been working, which included traveling throughout the eastern and northern parts of the state for contracted painting jobs. He reported that "some months he has done well and some he has not." He further reported that his mood "has been variable with some days feeling positive and others 'not even wanting to get out of bed.'" He had devised "a five-year plan to 'get myself back on my feet' which would include moving to Georgia later this year to be near his sister and her family which would also help him find work." The examiner also noted that the Veteran sounded "positive and hopeful". He denied any significant problems, and denied current suicidal or homicidal ideation, intent, or plan. A February 2012 VA clinical record reflects that the Veteran was alert, oriented, and had no thoughts of harming himself or others. A March 2012 VA clinical record reflects that the Veteran was alert, oriented times four, had a depressed mood, had no hallucinations or delusions, denied suicidal or homicidal ideas, and his medication was adjusted because of his depression and chronic pain. The records also reflect that the Veteran was drinking alcohol below the recommended limits. An August 2012 VA clinical record reflects that the Veteran continued to describe depression and difficulty coping with his physical pain. The Veteran talked of his connection to his children and the support he tries to provide to them. The Veteran also reported that his son has been reaching out to him. The Veteran reported that he planned to move to Georgia, where his sister wanted to have him work at a school where she is employed. Upon examination, the Veteran was appropriately groomed, had a cooperative and attentive attitude, fluent speech, and depressed mood. He had spontaneous, linear, logical, tangential thought flow. He had suicidal ideation without plan or intent. He denied homicidal ideation. He had fair judgment and fair insight. He had a GAF Score of 55. The probative value of a medical opinion is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guarneri v. Brown, 4 Vet. App. 467, 470-71 (1993). There is no requirement that additional evidentiary weight be given to the opinion of a medical provider who treats a veteran; courts have repeatedly declined to adopt the "treating physician rule." See White v. Principe, 243 F.3d 1378, 1381 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993) The Board finds based on the evidence noted above, that the Veteran's PTSD symptoms do not warrant a 100 percent rating for any period on appeal. Again, the Board is mindful that in order to be assigned a particular rating, a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. The Board has considered the examples in the rating criteria for a 100 percent evaluation and notes that the Veteran does not have gross impairment in thought processes or communication; persistent delusions or hallucinations, 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, or persistent danger of hurting self or others. The clinical opinions do not reflect total occupational and social impairment. While the Veteran has had some suicidal thoughts, the evidence does not reflect that he has been in persistent danger of hurting himself. In addition to not having the symptoms noted above, the Veteran is able to live by himself, has a close relationship with his two children, and is employed. Although, he was arrested twice, neither arrest was for violence towards himself or anyone else (one arrest was for destroying mail, and the other arrest was for using a gift card stolen from the mail). In addition, he has been employed at both the USPS and at a retail store. The evidence of record does not reflect that his PTSD interfered with his job at the retail store. He also maintains his own hygiene, has friends, and goes out in public. His GAF scores of 50, 55, and 58 are also evidence against a finding of total occupational and social impairment. The 2011 VA examiner stated that the Veteran's PTSD does not render him unable to secure or follow a substantially gainful occupation. The Board has considered the clinical findings, the Veteran's reported statements, and the GAF scores. As a whole, the evidence does not reflect that the Veteran has a total occupational and social impairment. The Veteran's symptoms are reflective of a disability which warrants no higher than a 70 percent evaluation. The Board has also considered that the Veteran has been prescribed medication for his mental health. The Veteran has been on medication since prior to the rating period on appeal, however, the evidence does not reflect that even without the medication, the Veteran's symptoms would warrant a 100 percent rating. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013). Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990) in assigning a rating of 70 percent and assigning an effective date of that rating as January 25, 2011. Extraschedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extra-schedular disability rating would be warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). The Board has reviewed the evidence of record and finds that it does not show such an exceptional disability picture. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule; hence, an extraschedular rating is not warranted. The rating formula for mental disorders allows for them to be rated based on the level of occupational and social impairment. While the code lists examples to be considered, the Veteran's PTSD-related symptoms have been considered, whether or not they are listed as an example. The evaluations are based on the severity of the Veteran's symptoms and the code allows for various evaluations based on levels of symptoms from mild or transient to those causing total impairment. Thus, regardless if the actual related symptom is listed in any criteria, it is still considered based on its severity. The Board finds that the Veteran does not experience any chronic symptomatology not contemplated by the rating schedule. Referral for extraschedular consideration is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). TDIU Entitlement to an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) and a TDIU extra-schedular rating under 38 C.F.R. § 4.16(b), although similar, are based on different factors. See Kellar v. Brown, 6 Vet. App. 157 (1994). An extra-schedular rating under 38 C.F.R. § 3.321(b)(1) is based on the fact that the schedular ratings are inadequate to compensate for the average impairment of earning capacity due to the Veteran's disabilities. In addition, exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, are required. In contrast, 38 C.F.R. § 4.16(b) merely requires a determination that a particular Veteran is rendered unable to secure or follow a substantially gainful occupation by reason of his or her service-connected disabilities. See VAOPGCPREC 6-96. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. Entitlement to TDIU is raised where a Veteran : (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In November 2008 and June 2009, the RO denied the Veteran's claim for entitlement to TDIU. The Veteran did not appeal those decisions and they became final. The evidence reflects that the Veteran was employed by the USPS until approximately 2007/2008, when he was suspended from his position at the USPS due to criminal charges. He began working at a retail store as an overnight stockperson, but was placed on unpaid leave from that position due to ongoing criminal charges. 2009 clinical records reflect that the Veteran was employed. 2010 VA clinical records reflect that the Veteran continued to work as a letter carrier with the USPS. As noted above, the November 2010 vocational rehabilitation specialist found that the Veteran was fully capable of obtaining and maintaining employment. 2011 VA records reflect that the Veteran had his own lawn care business, and was having difficulty due to the economy. 2012 VA records reflect that he was employed as a painter, and that his PTSD symptoms do not render him unable to secure or follow a substantially gainful occupation. His employment problems have been noted to be related to the economy and/or his felony conviction. In sum, the evidence is against a finding that a claim for TDIU has been reasonably raised by the record since the unappealed final denial in 2009. ORDER Entitlement to service connection for a left wrist disability is denied. Entitlement to an initial disability evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs