Citation Nr: 1416818 Decision Date: 04/15/14 Archive Date: 04/24/14 DOCKET NO. 11-12 625 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for headaches. REPRESENTATION Appellant represented by: Terri Perciavalle, Agent ATTORNEY FOR THE BOARD L. Reeder, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1951 to August 1955. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this appeal for further development in August 2011. In a November 2012 decision, the Board denied the claim for a higher initial rating for PTSD and remanded service connection for headaches. The Veteran appealed the Board's November 2012 decision to the Court of Appeals for Veterans Claims (Court). In an August 2013 Joint Motion for Partial Remand, the Secretary of VA and the Veteran moved the Court to vacate the Board's decision, but only as to the issue of entitlement to a higher initial rating for PTSD. The issue of entitlement to a TDIU was referred to the RO for appropriate action in the Board's August 2011 and November 2012 decisions. This issue has not yet been adjudicated by the Agency of Original Jurisdiction (AOJ), and is again referred to the AOJ. In August 2013 correspondence, the Veteran, through his representative, indicated that he wished to reopen a claim for service connection for a right eye condition. He also sought entitlement to an increased evaluation for a left leg condition, which likely refers to his service-connected residuals of frostbite, left lower extremity. As these claims have not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. In addition to the paper claims file, a paperless, electronic claims file is associated with the Veteran's claims, and has been reviewed. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002 & Supp. 2013). FINDINGS OF FACT 1. Since the effective date of service connection, the Veteran's PTSD has manifested with symptoms that more nearly approximate occupational and social impairment with reduced reliability and productivity. 2. In signed correspondence dated February 2014, prior to the promulgation of a decision, the Veteran withdraw his claim for entitlement to service connection for headaches. CONCLUSIONS OF LAW 1. Since the effective date of service connection, the criteria for an initial rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 2. The criteria for withdrawal of a substantive appeal by the Veteran on the issue of entitlement to service connection for headaches have been met. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2013); 38 C.F.R. §§ 20.101, 20.202, 20.204 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veteran's claim of entitlement to a higher rating for PTSD arises from his disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The VA has also fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of his claim and to provide a VA examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4)(i) (2013). VA has obtained service treatment and personnel records as well as post-service treatment records. The Veteran was afforded VA examinations in 2008 and in 2011. As the reports of the VA examinations were based on the Veteran's medical history and described the disability in sufficient detail so that the Board's decision is a fully informed one, the examinations are adequate to rate the disability. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). I. Higher Rating The Veteran seeks a higher initial rating for his PTSD which is evaluated as 30 percent disabling from July 16, 2008. The Veteran alleges that a 70 percent evaluation is most appropriate. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on social and occupational impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder the rating agency will consider the level of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). PTSD is rated under the criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411. The relevant rating criteria are as follows: A rating of 30 percent is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A rating of 50 percent 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 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. A rating of 70 percent is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A rating of 100 percent is assigned for 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. The Court has held that the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436 (2002). One factor which may be considered is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV)); see also Richard v. Brown, 9 Vet. App. 266 (1996). As applicable to this appeal, a GAF score of 51 to 60 indicates moderate symptoms (e.g., flattened affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 indicates some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or social functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The first post-service psychiatric treatment the Veteran received occurred in 2008, after he requested a refill of Cymbalta from a VA treatment center, stating it was prescribed for back pain but also helped relieve his symptoms of anxiety. As a result of that statement, the Veteran was referred for psychiatric evaluation in May 2008. At that time he indicated he had sleep problems, depressed mood, and flashbacks during which he would see his deceased friends from active service. The Veteran indicated he tended to avoid movies and programs related to the war in Korea, and that he cried easily. He denied suicidal or homicidal thoughts. The Veteran stated he had issues initially upon his separation from service, and that they resurfaced in approximately 2005. The reviewing physician prescribed citalopram for the Veteran's symptoms, and referred him to the PTSD clinic. The Veteran received the recommended PTSD evaluation in July 2008. He reported experiencing variable depression since his return from Korea, and stated that his mood had worsened after retirement. He indicated experiencing some decreased interest and appetite, but stated that citalopram had improved those symptoms. He denied symptoms of hypervigilance, hyperarousal, hyperstartle, or social avoidance. He denied any feelings of hopelessness or helplessness, and indicated that he never experienced suicidal or homicidal ideation. The Veteran also denied hallucinations. Regarding his social and occupational history, the Veteran reported working his way up through a steel company, where he eventually became vice president of manufacturing. He retired in 1995, at the age of 62. The Veteran indicated he had been married to his wife since 1956, and that they had a great relationship. He also described involved relationships with his children and grandchildren, and indicated he belonged to several clubs. He denied any social limitations. Based on a review of the Veteran's reported symptoms and his presentation during the evaluation, the examiner indicated the Veteran did not present with symptoms consistent with PTSD, but stated that it appeared he had been struggling with depressive disorder, not otherwise specified, since his retirement. The examiner assigned a GAF score of 70. The Veteran returned for a follow-up appointment that month, and stated he had downplayed his symptoms at his previous appointment, as he had always sought to avoid complaining. Based on the Veteran's explanation, additional individual therapy sessions were scheduled. In August 2008, the Veteran met with the same psychologist who, after evaluation, stated that the Veteran did appear to exhibit the full spectrum of symptoms consistent with PTSD. He diagnosed the Veteran with PTSD, assigned a GAF score of 70, and recommended initiating exposure therapy to address the Veteran's symptoms. During an exposure therapy session in August 2008, the psychologist indicated that the Veteran presented with an anxious mood. The Veteran recounted his experiences in Korea, and the psychologist reported that although he appeared under-engaged at first, the Veteran became very engaged as the session went on, crying at several points. The Veteran denied suicidal or homicidal ideation at that meeting. The psychologist assigned a GAF score of 70. In October 2008, the Veteran reported that he attended his high school reunion as part of an assignment for his therapy, but that it was a negative experience. The psychologist noted that the Veteran's mood was depressed, but that he denied suicidal or homicidal ideation. The psychologist assigned a GAF score of 60. During a session later that month, the Veteran reported completing an assignment of visiting a local casino, which he again stated was a negative experience. He indicated, however, that he was able to tolerate the anxiety the visit created. The Veteran's mood was again depressed, but he denied suicidal or homicidal ideation. The psychologist assigned a GAF score of 60. At his next session, the Veteran reported completing his assignment of visiting a shopping mall with his wife, but indicated it made him anxious. The psychologist reported that the Veteran's mood was depressed, but that he denied suicidal or homicidal ideation. He assigned a GAF score of 60. The Veteran was subsequently transitioned from exposure therapy to cognitive processing and group therapy sessions. In December 2008, the Veteran was afforded a VA PTSD examination. During that examination, the Veteran noted that he had experienced mild to moderate trauma-related symptoms while he was employed, including irritability, hyperarousal, nightmares, and hypervigilance. He stated he coped with the symptoms by taking long vacations when needed, but indicated that the symptoms did not interfere significantly with his employment or his relationships with other workers. The Veteran described a "good" relationship with his wife, and indicated that he saw his children and grandchildren regularly and enjoyed spending time with them. His typical day included running errands with his wife and visiting with family on occasion. The Veteran stated that his first psychiatric treatment was through VA in May 2008. He indicated that he had experienced no periods of remission since his trauma-related symptoms became problematic approximately ten years before. His subjective symptoms included mild hypervigilance and hyperarousal, moderate to severe sleep disturbances, intrusive memories, occasional detachment or estrangement from others, trauma-related nightmares approximately three to four times per week, irritability, guilt, experiential avoidance, low mood, feelings of hopelessness or worthlessness, and difficulty concentrating. Upon examination, the examiner noted that the Veteran was neatly groomed. He displayed a dysthymic mood with a fairly restricted, and sometimes tearful, affect. She stated that the Veteran denied symptoms of psychosis, and indicated that there was no evidence of delusion. She also stated that the Veteran denied suicidal or homicidal ideation. She observed that judgment and insight appeared to be fair to good. His memory was intact and he was fully oriented. The examiner diagnosed the Veteran with moderate, chronic PTSD, and assigned a GAF score of 60. She explained that the Veteran appeared to have experienced his current PTSD symptoms previously in his life, but that he was able to cope with them successfully by being employed and actively engaging in his occupational and social life. She stated that, after his retirement, his life became less stimulating and he decompensated, which resulted in his experiencing a full spectrum of trauma-related symptoms. She indicated that his symptoms had a moderate social and occupational effect, and that he likely had moderate difficulty developing effective interpersonal relationships. She subsequently stated she believed he would be unemployable, were he not already retired. In April 2009, during an individual therapy session, the Veteran endorsed continuing feelings of social isolation. He stated that he felt partially supported by the members of his therapy group, but that he was still determining whether he could fully trust them. Later that month, the Veteran presented for a doctor's appointment with a depressed mood. He stated that he was experiencing flashbacks approximately twice a week, as well as intrusive thoughts about his patrol duties in service. He indicated he had some suicidal thoughts, but that he would not hurt himself because of his wife. During his individual therapy session that same day, the Veteran denied suicidal or homicidal ideation, and indicated he was having positive experiences in group therapy. He was assigned a GAF score of 60. In October 2009, the Veteran stated, during a doctor's appointment, that he was still having nightmares, flashbacks, and intrusive thoughts about his in-service experiences, and was still trying to avoid war-related movies and news. The physician described his mood as dysphoric, but stated that he denied suicidal or homicidal ideation. During an individual therapy session in May 2010, the Veteran, when asked how he was doing, stated "I'm breathing." After discussing the death to which he was exposed during combat, the Veteran indicated he did not want to die, but that he was not afraid of death. In March 2011, the Veteran presented for a scheduled appointment with depressed mood and affect, and stated he was still having nightmares and flashbacks. He denied suicidal or homicidal ideation. In April 2011 the Veteran was noted to be cooperative and easily engaged during his PTSD group therapy session. His mood was noted to be euthymic, and his affect reactive. He denied suicidal or homicidal ideation. At a scheduled individual appointment in May 2011, the Veteran reported still having nightmares and intrusive thoughts, and was noted to have a dysphoric mood. He denied suicidal and homicidal ideation. In August 2011, the Veteran was again noted to have a euthymic mood and reactive affect, with no lethality issues, during his group therapy session. The Veteran was afforded a second VA PTSD examination in September 2011. At that time, he reported chronic symptoms of depression secondary to his PTSD, and indicated that he had thoughts of suicide that were occasionally active in nature. He denied any psychiatric hospital admissions. The Veteran stated he had been married for 53 years and that he had a close relationship with his wife. He reported seeing his family fairly frequently. The Veteran denied social contact outside of his family, but the examiner noted that the Veteran attended a weekly PTSD support group and appeared to engage socially with the members. The Veteran indicated that he and his wife left the house nearly daily, walked at the mall, had lunch, and ran other errands. The Veteran stated he did those activities because he knew they were good for his wife. The Veteran denied ever missing work due to his PTSD prior to retirement. The examiner stated that the Veteran's impairment in social functioning was moderate. The examiner indicated that the Veteran's mood at the time of examination was dysphoric, with constricted affect, and the Veteran reported a depressed mood with limited interest and pleasure in activities. The examiner indicated that the Veteran's judgment and insight appeared to be largely intact, and that his thoughts were logical and coherent. The Veteran stated he had daily intrusive recollections and nightly dreams of combat experiences. He also reported experiencing once-weekly panic attacks. He indicated feeling detached or estranged from others and feeling a sense of a foreshortened future. He also stated he had difficulty sleeping and concentrating. The Veteran reported experiencing visual and auditory hallucinations, and stated that he avoided military-related movies and discussions about military topics, as they were distressing to him. The examiner again noted that the Veteran attended weekly PTSD support groups with other Veterans, and that he had indicated his enjoyment of those sessions on various occasions. He stated that the Veteran did not appear to experience visual or auditory hallucinations during evaluation, and that no delusions were elicited. Regarding his report of suicidal ideation, the Veteran indicated that those feelings had intensified in the past six months. He stated he did not tell his treatment providers because he thought they would not understand. Based on the Veteran's statements, the examiner arranged a meeting with the Veteran's PTSD group therapy leader that day. Upon reporting for that appointment, the Veteran stated that he did not intend to kill himself, but that if anything happened to his wife, who was in good health, he would think about killing himself. The group therapy leader stated that the Veteran's mood was pleasant and euthymic, and that he displayed full affect. During a suicide risk assessment also conducted that day, the Veteran reported severe emotional distress, anxiety, panic symptoms, hopelessness, insomnia, and hallucinations. He stated he tended not to be fully honest to his providers about his suicidal ideations. The clinician conducting the evaluation indicated the Veteran had baseline increased suicide risk factors. After reviewing the other evaluations conducted on the day of the examination, the VA examiner diagnosed the Veteran with moderate, chronic PTSD, and assigned a GAF score of 55. He opined that the Veteran's PTSD symptoms were somewhat worse than those reported during the 2008 VA examination, but stated that, based on the Veteran's presentation during the examination, as well as his presentation to his PTSD group therapy leader that same day, he judged the Veteran's current symptoms to be moderate, causing moderate social and industrial disability. The examiner stated that the Veteran was fully employable, as he would likely be able to tolerate the schedule requirements, stress, and interpersonal interactions required to maintain employment without experiencing an exacerbation of psychiatric symptoms and need for hospitalization. On review of the evidence of record, considering the VA records, the GAF scores in the range of 55 to 70, the reports of VA examinations, as well as the Veteran's competent and credible lay statements, the Board finds that the Veteran's PTSD most closely approximates the criteria for a 50 percent rating since the grant of service connection. The Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbance of sleep, nightmares, intrusive thoughts, constricted affect, panic attacks, depression, occasional feelings of hopelessness, anxiety, flashbacks, mild hypervigilance, and avoidance of traumatic thoughts/events during service. Although many of the Veteran's symptoms do not, alone, rise to the level of those enumerated in the 50 percent rating criteria, both VA examiners reported moderate social and occupational impairment due to the symptoms of PTSD. Thus, the Board finds that a 50 percent rating is warranted. As for a rating higher than 50 percent, considering the VA records, including the GAF scores in the range of 60 to 70, the reports of VA examinations, as well as the Veteran's competent and credible lay statements, the Veteran's PTSD does not more nearly approximate or equate to the criteria for a 70 percent rating, namely, impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. In correspondence dated in March 2014, the Veteran's representative stated that the Veteran's symptoms, including nightmares, flashbacks, depressed mood with crying spells, severe sleep problems associated with nightmares, sense of a foreshortened future, evidence of unemployability, irritability, intrusive thoughts, panic attacks, difficulty concentrating, hypervigilance, and suicidal ideation warranted a 70 percent disability evaluation. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit held that a Veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. This holding is of particular significance here, as the claimant in that case also alleged that a rating higher than 50 percent for PTSD was appropriate. The Federal Circuit held that in the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Although a Veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the Veteran's level of impairment in "most areas." The Federal Circuit also stated that entitlement to a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation. The Veteran has at times reported suicidal ideation, continuous depression, and hallucinations, all of which are symptoms specifically noted in rating criteria for evaluations higher than 50 percent. However, the Veteran's reports of suicidal ideation have not been consistent. He endorsed some thoughts of suicide in April 2009 and at his VA examination in September 2011; however, he repeatedly denied suicidal ideation when questioned by his primary therapy team on various occasions throughout the appeal including in May 2008, July 2008, August 2008, and the December 2008 VA examination, as well as immediately after endorsing suicidal thoughts at his September 2011 VA examination. It is not the type of symptoms, in this case, suicidal ideation, that is determinative of whether the criteria for the next higher rating have been met. It is the effect of the symptoms that is determinative. Stated in other way, the mere presence of suicidal ideation does not equate to the criteria for a 70 percent rating, rather it is the effect or degree of impairment in occupational and social functioning that needs to be determined. Here, the VA examiners concluded that the Veteran's disability was manifested by no more than moderate occupational and social impairment. Both VA examiners also reported that the Veteran's judgment and thinking appeared to be intact. Also, the GAF scores in the range of 55 to 70 are indicative of mild to moderate difficulty in social and occupational functioning. In the context of a GAF score, the effect of suicidal ideation is associated with serious impairment in social and occupational functioning. Although the Veteran has reported feelings of depression, the evidence does not reflect "near-continuous panic or depression affecting the ability to function independently." The Veteran's account of his daily activities during his VA examinations included assisting his wife in running errands, visiting the shopping mall, and dining out, as well as his frequent and timely attendance at therapy sessions and other appointments. This behavior does not support the conclusion that he is experiencing a level of continuous depression that is affecting his ability to function independently, appropriately, and effectively, nor has a medical professional found that to be the case. Finally, although the Veteran stated on several occasions that he experienced hallucinations, he described them only in the context of flashbacks, and demonstrated no other psychotic symptoms. While there is evidence of limited social interactions, there is no evidence that the Veteran is unable to establish and maintain social relationships as he has a close relationship with his wife and family members. He sees his children and grandchildren on a regular basis. He routinely participates in a PTSD support group, interacting with other Veterans and presenting with a euthymic mood and reactive affect. Although he once indicated that completing his homework assignments of appearing in public places made him anxious, he is reportedly able to leave the house daily to go to public places with his wife, including shopping malls and restaurants. With respect to deficiencies in the area of work, the Veteran reported a successful pre-retirement career, during which he lost no time due to symptoms of PTSD. Although the 2008 VA examiner opined that the Veteran would be unemployable were he not already retired, she also stated that, considering the Veteran's current level of PTSD-related symptomatology alone, it was likely that he had moderate difficulty developing effective interpersonal relationships in order to obtain and maintain gainful employment, suggesting that her assessment of unemployability was based on assessment of all of the Veteran's disabilities, not just PTSD. Additionally, the 2011 VA examiner opined that the Veteran was fully employable, as he would likely be able to tolerate the schedule requirements, stress, and interpersonal interactions required to maintain employment. The Board has considered the Veteran's assertions as to his symptomatology and severity of his condition, as well as the lay statement provided by his wife, but finds that the observations made during objective medical evaluation are more probative than those lay assertions. Even viewing all of the Veteran's reported symptoms in the light most favorable to him, the record still does not reflect that his PTSD symptoms cause occupational and social impairment with deficiencies in most of the enumerated areas, as is required to warrant a higher rating of 70 percent under the Federal Circuit's holding in Vazquez-Claudio. And the evidence does not more nearly approximate or equate 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 ability 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. For the foregoing reasons, the Board finds that an initial rating of 50 percent from the date of service connection is warranted, but the preponderance of the evidence is against a rating higher than 50 percent at any time during period. Other Considerations Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability levels and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned ratings are adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Comparing the Veteran's disability level and symptomatology to the Rating Schedule, the degree of disability is encompassed by the General Rating Formula for Mental Disorders under Diagnostic Code 9411, and the assigned schedule rating is adequate. In other words, the Board finds that the rating criteria reasonably describe the Veteran's disability and symptomatology, and the Veteran does not have symptomatology not already encompassed by the General Rating Formula. For this reason, referral for an extraschedular rating is not warranted under 38 C.F.R. § 3.321(b)(1). II. Withdrawn Appeal Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b). In a February 2014 written statement, the Veteran, through his representative, indicated that he was withdrawing his appeal on the issue of entitlement to service connection for headaches. The Veteran's correspondence satisfies the requirements for withdrawing an appeal, and there are not, therefore, any remaining allegations of error of fact or law for appellate consideration with respect to that claim. Accordingly, the Board does not have jurisdiction to consider an appeal in that matter, and it is dismissed. ORDER An evaluation of 50 percent, but no higher, for PTSD is granted for the entire period of the claim, subject to the rules and regulations governing the payment of VA monetary benefits. The claim of entitlement to service connection for headaches is dismissed. ____________________________________________ D. JOHNSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs