Citation Nr: 1413086 Decision Date: 03/27/14 Archive Date: 04/08/14 DOCKET NO. 08-36 538 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from September 1969 to September 1973 and from December 1973 to November 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision by the Cleveland, Ohio, Regional Office (RO) of the Department of Veterans Affairs (VA). The Board notes that a February 2009 rating decision also denied entitlement to a total disability rating based upon individual unemployability as a result of service-connected disabilities (TDIU) and that the Veteran did not appeal that determination. The United States Court of Appeals for Veterans Claims (hereinafter "the Court"), however, has held that a claim for entitlement to TDIU is a rating theory and "not a separate claim for benefits." See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Bifurcation of a claim is generally a matter within VA discretion. Id. at 455, n. 7. The Board finds that the TDIU issue in this case involved multiple complex medical issues and was more appropriately addressed as a separate issue. As the Veteran did not timely appeal the February 2009 decision denying a TDIU, the matter is not presently for appellate review. The Board notes, however, that the Court has held that entitlement to an extraschedular rating under 38 C.F.R. § 3.321(b)(1) and a TDIU extraschedular 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). Therefore, the extraschedular rating issue is addressed as part of the increased rating issues on appeal. In February 2012, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, D.C. to afford the Veteran a VA medical examination. The action specified in the February 2012 Remand completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT The Veteran's PTSD was most appropriately characterized throughout the period on appeal by occupational and social impairment with reduced reliability and productivity due to such symptoms including, but not limited to: flattened affect; disturbances of motivation and mood; and difficulty establishing and maintaining effective work and social relationships. CONCLUSION OF LAW The criteria for entitlement to an initial disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has reviewed all of the evidence in the claims folder. 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 United States Court of Appeals for the Federal Circuit (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 these claims. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R., Part 4 (2013). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2013). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the veteran's increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the Court held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. The Veteran was granted entitlement to service connection for a PTSD with depressive disorder in a June 2008 RO decision, which assigned an initial disability evaluation of 50 percent, effective March 5, 2007. The Veteran's PTSD with depressive disorder is rated under the General Rating Formula for Mental Disorders, found at 38 C.F.R. § 4.130 (2013). A 50 percent evaluation is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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; difficult establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where 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; intermittently illogical, obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where 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; and memory loss for names of close relatives, own occupation, or own name. Id. It is further noted that the nomenclature employed in the portion of VA's Schedule for Rating Disabilities ("the Schedule") that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2013). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. GAF scores ranging between 61 and 70 are assigned when there are 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 when the individual is functioning pretty well and has some meaningful interpersonal relationships. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th. ed., 1994). GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when 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. GAF scores ranging between 31 and 40 are assigned when there is 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). Id. GAF Scores between 21 and 30 are assigned when behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). Id. Symptoms listed in VA's general rating formula for mental disorders 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). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a) (2013). In addition, the evaluation must be 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. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2013). In this case, the Veteran contends that his PTSD is more severe than reflected by the present 50 percent evaluation. He has asserted that a 100 percent rating is warranted and that he is unemployable as a result of his PTSD, although the record shows he was until recently working fulltime. In correspondence received by VA in March 2009 the Veteran reported, in essence, that he had PTSD symptoms, including suicidal and homicidal ideation, which warranted at least a 70 percent rating. The Veteran was first seen in March 2006 for mental health problems. At a March 2006 VA Mental Health Outpatient appointment, he reported a history of mental health problems since his return from Vietnam. The Veteran described nightmares, depression, sleep problems, and anxiety, especially in crowds. The Veteran's mood was anxious, but his affect was appropriate and he was cooperative. He appeared alert and well oriented, with no evidence of paranoia or perceptual disturbances. He denied suicidal or homicidal ideations. He was diagnosed with Depressive Disorder and Anxiety Disorder. At a March 2006 Comprehensive Mental Health Evaluation, the Veteran reported experiencing constant fear and threats to his life when serving in Vietnam, and he began drinking alcohol heavily to cope with his fear. When he first returned from Vietnam, he experienced flashbacks, but was no longer bothered by this symptom. Current symptoms included infrequent vivid nightmares; frequent, recurrent intrusive thoughts of Vietnam; and fitful sleep. The Veteran complained he often felt emotionally numb, sometimes depressed and sometimes irritable with angry outbursts. He reported a history a physical altercations, but explained that he was now able to walk away from confrontations. He described a preference for solitary activities and a tendency to isolate from others. Leisure activities included riding his motorcycle, watching sitcoms on television, and when the weather was warm, doing yard-work and swimming. He actively avoided reminders of war. The Veteran was twice divorced and resided with his third wife. He described his third marriage as comfortable. The Veteran also had two grown sons. At the time of the assessment, the Veteran had worked as a social worker for almost twenty years and stated that he enjoyed his work. The Veteran was observed to be alert and well-oriented, with good grooming and hygiene. His manner was polite, albeit somewhat guarded. His mood appeared moderately depressed and his affect was restricted, congruent with his mood and the conversation. Thought processes were relevant and coherent, without any evidence of hallucinations or delusions. Concentration and memory appeared intact, as did judgment and insight. The Veteran admitted to past suicidal ideation, but denied any current. The Veteran was given a provisional diagnosis of PTSD, rule out depressive disorder. A GAF score of 55 was assigned. At a November 2006 VA Mental Health Outpatient appointment, the Veteran was doing better with medication and therapy, but reported occasional suicidal ideations with no intent or plan. At a February 2007 evaluation, he reported continued daily intrusive thoughts and images. He also complained of nightly sleep disturbances, with nightmares approximately twice a week. He reported improved depression and anxiety, with an overall more stable mood. He also thought his irritability and concentration had slightly improved. He continued to report isolation and avoidance. He denied any current suicidal or homicidal ideations, but did report episodic suicidal ideations over the past year. He denied any history of suicide attempts. GAF score was 60. In April 2008, the Veteran was afforded a VA examination. At that time, the Veteran described symptoms of anxiety, depression, anger, and irritability. He reported passive suicidal ideations approximately twice a year, but denied any suicide attempts or gestures. He complained of difficulty concentrating at work due to flashbacks and intrusive thoughts. He reported episodes of anger dyscontrol, with verbal outbursts towards his spouse and son. He had also had episodes of road rage and stated that he has followed other motorists to their destination and engaged in verbal altercations with them. He recounted vague, non-specific homicidal ideation when angry, but denied any attempts or gestures. The Veteran described his current marriage as "loving and satisfying" and reported a close relationship with his two sons and his grandchildren. He reported frequent contact with these family members, including going out to eat with them on a regular basis and taking his grandchildren to the park or mall. The Veteran also reported a "very good" relationship with his siblings. He also reported a twenty-five year history of employment as a case manager for a local community action agency. The Veteran reported that he was a member of the Run for the Wall motorcycle club and rode weekly with fellow cyclists. He also performed yard work, went four-wheeling, and watched television. The Veteran was reported to be cooperative with the examination, although his manner was slightly anxious and his affect restricted. His grooming and hygiene were within normal limits and he was appropriately attired. His speech was spontaneous, with normal rate, rhythm, clarity, and volume. The Veteran was oriented to time, place, person, and purpose, although the examiner did observe that during flashbacks, the Veteran experiences brief and transient disorientation to time and place. The Veteran's attention, concentration, and memory were slightly impaired. The examiner characterized the Veteran's abstract reasoning ability as slightly impaired due to concrete interpretation. Under stress, his logical problem-solving was compromised and he responded with frustration and impulsivity, specifically with verbal outbursts. His verbal outbursts were also seen as evidence of slightly impaired judgment. However, the Veteran's thought process was organized, goal-oriented, and logical. He had intact reality contact and no evidence of hallucination, delusions, or other perceptual abnormalities. The Veteran was diagnosed with depressive disorder not otherwise specified secondary to PTSD, of moderate intensity. The examiner concluded that the Veteran was not rendered unemployable by his PTSD, but would suffer moderate impairment of occupational functioning secondary to his disability. A GAF score of 57 was assessed. The Veteran was afforded another VA examination in October 2010. At that time, the Veteran reported limited energy and motivation which affected his productivity, as well as frequent irritability and a low frustration tolerance. He also reported insomnia. He complained of decreased concentration due to daily intrusive thoughts, as well as of difficulty listening to his patients' problems. He described feeling "down." He reported that he avoided most social interactions with non-family or non-veterans. He indicated that he had a history of suicidal thoughts and plans, but denied any current suicidal ideations or past suicidal acts. While in the past he drank heavily and his use was a problem, he currently only drank occasionally. The Veteran claimed that if he heard people talking about issues related to veterans, he would often become enraged. He stated that he had screamed at and hit people doing so; however, he denied any legal problems as a result of his aggression. He also reported road rage, stating that he would yell at other drivers and cut them off, but he denied that he would chase or follow them. The Veteran reported that he had been married to his spouse for ten years and that they engaged in activities together such as going out to eat, taking walks, or riding bikes "as often as possible." He reported a close relationship with his younger son, but not his eldest, as well as a close relationship with his wife's grandchildren, whom he saw regularly. He also saw his brother regularly and reported a close relationship. He had regular contact with his eldest sister, but not the youngest. He stated that he was close with several motorcycle riders who were also veterans and part of the Run for the Wall group. In additional to his motorcycle riding, his reported leisure activities included watching television and taking walks or eating out with his wife. The Veteran was clean and neatly groomed. He was cooperative and attentive with the examiner, but his mood was depressed and his affect restricted. The Veteran was well oriented and there was no evidence of significant attention difficulties. There was no evidence of any thought disorder or memory problems. The Veteran did not have panic attacks or engage in obsessive or ritualistic behavior. The examiner determined that the Veteran understood the outcome of his behavior and understood that he had a problem. The examiner concluded that the Veteran is not unemployable due to his disability, but his depressive disorder and PTSD symptoms do cause reduced reliability and productivity. A GAF score of 60 was provided. The Veteran was most recently afforded a VA examination in March 2012. He complained of recurrent intrusive thought and recollections of traumatic events, feelings of detachment or estrangement from others, avoidance, difficulty falling or staying asleep, irritability and outbursts of anger, depressed mood, and anxiety. He also reported difficulties with concentration and memory, although the examiner found the Veteran to be cognitively intact and noted that the Veteran's reported difficulties were largely age-appropriate. The Veteran reported that he generally got along well with his spouse, children, step-children, and grandchildren, although he could be "grouchy." He also reported having a few close friends. His leisure activities included riding his motorcycle, maintaining his property, reading magazines, watching television, and going out to dinner or riding with his wife. He described his employment as a social worker as "tough" because he did not like to listen to others' problems when he had problems of his own, and stated that he was planning to quit in a few months. The Veteran was diagnosed with depressive disorder, NOS, and anxiety disorder, NOS. The examiner opined that the Veteran's disability would result in occupational and social impairment with occasional decrease in work efficiency and ability to perform occupational tasks, although he would generally function satisfactorily, with normal routine behavior, self-care, and conversation. The examiner concluded that the Veteran remains employable from a mental health perspective, and that some improvement in his symptoms would actually be likely if successful employment could be achieved. A GAF score of 55 was assigned. The Board has also reviewed VA outpatient treatment records which show ongoing individual therapy sessions from 2006 through the present. The Veteran has consistently described similar symptoms to those previously noted and while the Veteran has sometimes reported that he was doing quite well, while at other times he has reported struggling, the record reflects that his condition has generally remained stable during the period on appeal, with GAF scores ranging from 50 to 65. Treatment records show that the Veteran has benefited from his ongoing participation in the Run for the Wall cross-country motorcycle rides and a January 2013 Mental Health Outpatient Notes documents that the Veteran had started meeting with other retirees for coffee/breakfast several times a week which he reportedly found very enjoyable. However, he reported increasing frustration with the demands of his job, and he quit in June 2012. He also began attending group therapy in September 2013. A November 2013 VA mental health treatment notes reflects that the Veteran was struggling with a period of serious depression and reported suicidal ideations, but the Veteran denied any intent or plan to kill himself. He did report improvement in controlling his anger and impulses, following participation in an anger management program, and stated that he no longer snapped at his wife as much as in the past. He also felt his social anxiety was somewhat improved. Based on all the above evidence, the Board finds that an initial disability rating in excess of 50 percent for the Veteran's service connected PTSD is not warranted. The Veteran has consistently reported symptoms such as intrusive thoughts and dreams of combat experiences, avoidance, poor concentration, sleep disturbances, anxiety, and depressed mood. However, the effect of these symptoms on the Veteran's occupational and social functioning appears to be no more than moderate. Despite his mental health problems, the Veteran has reported having a loving relationship of many years with his current wife and a good relationship with his children, grandchildren, and siblings. The Veteran has also reported involvement in a motorcycle riding organization, veterans groups, and most recently, an informal meeting of fellow retirees, as well as engagement in a number of hobbies such as riding his motorcycle, four-wheeling, swimming, working outdoors, and watching television. Thus, it appears that the Veteran has a number of close personal relationships that provide him with support and that he is socially engaged. Additionally, the Veteran has described a stable work history prior to his recent retirement with no significant conflict with supervisors or coworkers. The March 2012 VA examiner concluded that the Veteran's PTSD would not prevent him from finding or maintaining substantially gainful employment, and would in fact likely be helpful to the Veteran. All the VA examiners, as well as the Veteran's mental health treatment providers, have found no evidence of any thought disorder. The Veteran has consistently been described as well oriented, with appropriate grooming and affect. He has been able to communicate coherently and logically with medical professionals, as well as VA employees. There is no evidence of mania or psychosis. The Board notes that the symptoms and level of impairment described by the General Formula for Rating Mental Disorders for a disability that is 70 percent disabling, such as "obsessional rituals that 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"; and "neglect of personal appearance and hygiene" indicate an individual that is severely debilitated by his psychiatric disability, and with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood. The preponderance of the evidence is against a finding that the Veteran's PTSD is so disabling. GAF score throughout the period on appeal have ranged from a low of 50 to a high of 65, indicating generally at most a moderate disability. There is no evidence of any significant change for better or worse during the period on appeal; accordingly, assignment of staged ratings is not appropriate. While the Veteran has reported a history of suicidal and homicidal ideations, the Board notes that the available VA examination and treatment reports include some inconsistent findings as to his history of suicidal and homicidal ideation and suicidal attempts. VA treatment records include an April 2010 report which noted the Veteran had past suicide attempts, the last of which was several years earlier. All three VA examination reports, however, noted he had suicidal and homicidal thoughts with no history of attempts or gestures. The overwhelming majority of VA outpatient treatment notes also show that the Veteran has reported suicidal ideations, but has denied any attempts. The Board has considered the Veteran's assertions that his disability is not appropriately rated, but the Board gives greater weight to the accounts of the Veteran's symptoms documented in VA examination reports and in the Veteran's VA outpatient treatment records, with particular weight given to the assessments made by trained mental health professionals regarding the severity of the Veteran's disability. There is also no evidence that the Veteran was ever voluntarily or involuntarily committed for psychiatric problems, including suicide attempts, or indeed received any inpatient therapy. Additionally, it does not appear that the Veteran has had any legal or professional repercussions related to his PTSD. Finally, the Board has also considered whether the Veteran's disability warrants referral for extraschedular consideration. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2013). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board finds that the schedular rating criteria reasonably reflect the Veteran's disability levels and symptomatology. In this case, it does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is not required. See Thun, supra. For all the above reasons, entitlement to an initial disability rating excess of 50 percent for PTSD with depressive disorder is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2013). The Duty to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2013). Here, the Veteran was provided with the relevant notice and information in a February 2008 letter prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). He has not alleged any notice deficiency during the adjudication of his claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA also has a duty to assist the Veteran in obtaining potentially relevant records, and providing an examination or medical opinion when necessary to make a decision on the claim. Here, the Veteran's service records, VA records, and identified private treatment records have been obtained and associated with the claims file. The Veteran was also provided with VA examinations which, collectively, contain a description of the history of the disability at issue; document and consider the relevant medical facts and principles; and provide opinions regarding the etiology of the Veteran's claimed condition. In a September 2012 statement, the Veteran complained that the March 2012 VA examination was not sufficiently comprehensive and did not accurately reflect the severity of his disability. However, in March 2012, the Veteran told his VA therapist that his recent VA examination seemed more "in-depth" than he was used to. Furthermore, a review of the March 2012 VA examination discusses the Veteran's psychiatric disability in detail. Therefore, the Board finds the Veteran's contention that he was not afforded an adequate examination is without merit. VA's duty to assist with respect to obtaining relevant records and an examination has been met. 38 C.F.R. § 3.159(c); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). ORDER Entitlement to an initial disability rating in excess of 50 percent for PTSD with depressive disorder is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs