Citation Nr: 1418036 Decision Date: 04/22/14 Archive Date: 05/02/14 DOCKET NO. 09-10 837 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to September 9, 2013, for posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 50 percent on and after September 9, 2013, for PTSD. REPRESENTATION The Veteran is represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Sean G. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from June 1965 to June 1967. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire. The Veteran's claim was previously before the Board in July 2013, at which time it was remanded for additional development. While in remand status, the RO assigned a 50 percent rating to the Veteran's PTSD, effective September 9, 2013. After a December 2013 supplemental statement of the case, the appeal has been returned to the Board for further appellate review. A total rating based on unemployability due to service-connected disability (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. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran has not argued, and the record does not otherwise reflect, that the disability at issue renders him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised and, thus, the Board will not address such a claim herein. Id. FINDINGS OF FACT 1. Prior to September 9, 2013, the Veteran's PTSD is manifested by symptoms that cause or more nearly approximate 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. 2. On and after September 9, 2013, the Veteran's PTSD is manifested by symptoms that cause or more nearly approximate occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. Prior to September 9, 2013, the criteria for an initial rating in excess of 30 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 2. On and after September 9, 2013, the criteria for a rating in excess of 50 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In March 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and/or an effective date will be assigned if service connection is awarded. In correspondence dated in October 2007, VA informed the appellant of what evidence was required to substantiate his claim for service connection for PTSD, and his and VA's respective duties for obtaining evidence. It also notified him that a disability rating and effective date would be assigned, in the event of award of the benefit sought, as required by the Court in Dingess/Hartman and explained how disability rating are assigned. Because the March 2008 rating decision granted the Veteran's claim for service connection for PTSD, this claim is now substantiated. His filing of a June 2008 notice of disagreement does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3). The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records and VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In July 2013, the Board remanded the Veteran's claim in order to attempt to obtain treatment records from the Manchester, New Hampshire Vet Center. The RO sent the Vet Center two requests, one dated in September 2013, the other dated in November 2013, for the Veteran's relevant treatment records. The RO did not receive a response. The Board finds that the RO undertook all reasonable efforts to obtain the Veteran's treatment records from the Vet Center, and that further attempts would be futile. In November 2013, the RO sent the Veteran a letter notifying him of its efforts to obtain his treatment records from the Vet Center. The RO further notified him that he was ultimately responsible for obtaining and submitting any relevant evidence. The Veteran did not independently submit the relevant treatment records from the Vet Center. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (noting that the duty to assist is not always a one- way street); Turk v. Peake, 21 Vet. App. 565, 568 (2008) (holding that VA's duty must be understood as a duty to assist the Veteran in developing his claim, rather than a duty on the part of VA to develop the entire claim with the Veteran performing a passive role). Beyond the Vet Center treatment records, there was no indication that additional evidence relevant to the issues being decided herein was available and not part of the record. See Pelegrini, 18 Vet. App. at 120. The Veteran was afforded VA examinations in March 2008, May 2011, and September 2013. The examiners reviewed the Veteran's claims file, treatment records, and reports of clinical examinations, and administered thorough clinical evaluations, which provided findings pertinent to the rating criteria, and all of which allowed for fully-informed evaluations of the disability at issue. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In making this determination, the Board observes that the September 2013 VA examiner found that no additional evidence showing psychiatric treatment had been associated with the claim file since the prior examination (in May 2011). Contrary to the examiner's finding, the evidence of record included an August 2012 opinion from a medical professional at the Manchester, New Hampshire Vet Center. Although it appears that the September 2013 VA examiner did not review this evidence, the Board finds that the Veteran was not prejudiced. This is so because the August 2012 opinion questions the validity of the Veteran's ongoing PTSD diagnosis, finding that the Veteran exhibited sub-diagnostic symptoms. As this evidence would not serve to benefit the Veteran's claim, the Board finds that the September 2013 VA examiner's failure to review it does not undermine the adequacy of the examination. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the Veteran's claim, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). 38 C.F.R. § 3.103(c)(2) (2013) requires that a hearing officer fulfill two duties in order to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issue(s) and (2) the duty to suggest the submission of evidence that may have been overlooked. During a December 2008 Decision Review Officer hearing, the Veteran was assisted by an accredited representative from Disabled American Veterans. The representative and the Decision Review Officer asked questions to ascertain the severity of the Veteran's disability. The hearing focused on the symptoms the Veteran associated with his PTSD and the effect these symptoms have on his ability to function occupationally, socially, and in his daily life. Through his testimony, the Veteran demonstrated actual knowledge of the requirements to attain a higher rating. No pertinent evidence that might have been overlooked and that could substantiate the claim was identified by the Veteran or the representative. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that the hearing officer complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2013). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Staged ratings are appropriate whenever the factual findings show distinct periods in which a disability exhibits symptoms that warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21 (2013). Therefore, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Veteran submitted the claim at issue herein in March 2007. Service connection has been established for PTSD effective from March 29, 2007. As such, the rating period for consideration is from March 29, 2007. According to the General Rating Formula for Mental Disorders, PTSD is rated at 30 percent when there is 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, or mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation is warranted for PTSD when there is 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for PTSD where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted for PTSD when there is total occupational and social impairment, due to such symptoms as: persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. Id. A GAF score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. Id. A GAF score of 41-50 is assigned where there are, "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. I. Prior to September 9, 2013, Prior to September 9, 2013, the Veteran was assigned a GAF score of 55 (during the March 2008 and May 2011 VA examinations), indicating moderate symptoms or moderate difficulty in social, occupational or school functioning. As demonstrated by a February 2009 private PTSD evaluation, the Veteran was assigned a GAF score of 45, indicating serious symptoms or any serious impairment in social, occupational, or school functioning. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record relevant to this time period and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2013); VAOPGCPREC 10-95. Prior to September 9, 2013, the Veteran's service-connected PTSD was manifested by symptoms that result in occupational and social impairment as follows: With respect to familial relationships, in a September 2007 statement, the Veteran's spouse said that the Veteran had become depressed and "nasty," which affected their marriage of 38 years. She indicated that he was getting in fights with her, their daughter, and their 9 year old grandson. She stated that the Veteran would forget his own telephone number, but that he remembered the phone number for a local Veterans Service Organization. The Veteran's wife stated that the Veteran would "sneak out" to this Veterans Service Organization "every night." During the March 2008 VA examination, the Veteran reported that he had been married to his wife for 38 years. This was his first marriage. With respect to his relationship with his wife, the Veteran stated that they had their "moments," without further elaboration. He later endorsed yelling and getting upset over "dumb" things and that he had a normal sex drive. He indicated that he was able to help around the house with cleaning and grocery shopping. The Veteran stated that he and his wife have two children (a son and a daughter), with whom he had "very good" relationships. He also reported occasionally visiting with other family members and extended family. In May 2011, the same VA examiner indicated that the Veteran continued to be married to his first wife of more than 41 years. The examiner reviewed the Veteran's March 2008 VA examination results, characterizing the Veteran's then relationship to his wife as "not so good." The Veteran then echoed his March 2008 statements about his marriage to his wife, saying that they had their "moments," without further elaboration. The Veteran described his relationship with his children as "typical." He endorsed helping with household cleaning, but stated that he did not go grocery shopping by himself. He also enlisted the help of his son-in-law to do yard work. With respect to social functioning, during the March 2008 VA examination, the Veteran stated that he had friends at his local Veterans Service Organization with whom he socialized. He denied having any hobbies and participating in recreational activity, but endorsed having his driver's license and had no difficulties driving. The examiner opined that the Veteran's PTSD mildly to moderately interfered with his ability to function socially. During the May 2011 VA examination, the Veteran endorsed having friends, and that his only hobby was reading. The Veteran continued to maintain his driver's license, but stated that he did not like driving far distances due to nervousness. The examiner opined that the Veteran's PTSD symptoms moderately interfered with his social functioning. With respect to work history/occupational functioning, the March 2008 VA examiner determined that the Veteran's PTSD symptoms mildly interfered with his employment functioning, but also stated that the Veteran functioned "moderately well" while at work. The examiner opined that the Veteran's PTSD symptoms would result in an occasional decrease in his work efficiency and an inability to perform occupational tasks "at times." In May 2011, the examiner indicated that the Veteran continued to work in quality review at a defense system company, an occupation that he had been performing for the previous 28 years. The Veteran stated that his work has been rated as "good," but that he had been "talked to" about his anger. He worked on a full-time basis. The Veteran described himself as a "good worker," and worked regardless of how he felt emotionally. The examiner concluded that the Veteran's PTSD symptoms mildly or moderately interfered with employment functioning, finding that they resulted in an occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks. Concerning overall functional impairment, the March 2008 VA examiner opined that the Veteran's PTSD symptoms were moderate in nature, and that he was dependent on alcohol; but that, generally, the Veteran was satisfactorily functioning with routine behavior, self-care, and normal conversation. Additionally, in February 2009, the Veteran underwent a private PTSD evaluation, which was preceded by ongoing therapy that began in April 2008. The examiner ultimately rendered a diagnosis of PTSD, and determined that the associated symptoms were severe enough to affect all aspects of the Veteran's life, including occupational, interpersonal relationships, and activities of daily life. The examiner stated that the Veteran's PTSD symptoms developed and worsened over time, and eventually included or resulted in irritability, social withdrawal, marital discord, and alcohol dependence. During the May 2011 VA examination, the Veteran reported that he had stopped drinking alcohol, and had refrained from doing so for the previous 3 weeks, which the examiner characterized as early remission. The examiner rated the Veteran's symptoms as moderate in nature, but noted that there was no impairment of thought process or communication, and that the Veteran was able to maintain personal hygiene and daily responsibilities. Further, the examiner found that the Veteran was generally satisfactorily functioning in routine behavior, self-care, and normal conversation. As part of the diagnosis, the examiner rendered an Axis IV diagnosis of problems with primary support group, problems related to social environment, and occupational problems. According to an August 2012 PTSD evaluation by the Vet Center, the Veteran underwent a series of 7 sessions beginning in July 2011. Based on these sessions, the examiner determined that the Veteran exhibited symptoms that were "sub-diagnostic" for PTSD, but that the Veteran had a "stale mood" in December 2011. The Veteran stated that he had been sober for five months prior to the initial session in July 2011, during which he endorsed an increase in nightmares. By December 2011, however, the examiner stated that the Veteran resumed "homostasis" and that his mood was stable. As discussed above, the Veteran's PTSD has already been assigned a 30 percent rating prior to September 9, 2013. Thus, in order for a higher rating to be warranted, the evidence of record relevant to this period of time must demonstrate that the Veteran's PTSD caused or more nearly approximated occupational and social impairment with reduced reliability and productivity. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). As demonstrated above, various medical professionals deemed the Veteran's PTSD symptoms, prior to September 9, 2013, to be moderate to moderately severe in nature, with one instance of serious symptoms or serious impairment. Further, the evidence demonstrated that the Veteran had a "not so good" relationship with his wife; fought with his wife, daughter, and grandson; and was talked to by his mangers/bosses about his anger. Additionally, the Veteran's PTSD was manifested by or caused irritability, social withdrawal/isolation, and marital discord. Despite the presence of these symptoms, the resulting functional and occupational impairment, and the underlying GAF scores, the Veteran was able to successfully attend to the tasks associated with this full-time professional in quality control at a defense system company; continue his marriage to his first wife of more than 40 years; maintain social relationships with friends at a Veterans Service Organization; occasionally visit with extended family; and have "very good" to typical relationship with his children. Further, the Veteran characterized himself as a good worker that would work regardless of his emotional status. Moreover, he was able to attend to personal hygiene, daily responsibilities, and routine behavior. Based on this, the Board finds that the Veteran's PTSD does not cause or more nearly approximate occupational and social impairment with reduced reliability and productivity. Consequently, the Board finds that a rating in excess of 30 percent prior to September 9, 2013, for the Veteran's PTSD is not warranted. Id. In making the above determination, the Board acknowledges the use of the term "such as" in 38 C.F.R. § 4.130, Diagnostic Code 9411, which demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Accordingly, the evidence considered in determining the level of impairment under Diagnostic Code 9411 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms associated with the Veteran's PTSD that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. Id. While the Veteran's PTSD may be manifested by some symptoms that are associated with higher ratings, the Board finds that the Veteran's PTSD disability picture does not more nearly approximate the criteria for those ratings. 38 C.F.R. § 4.7. As such, the Board finds that the criteria for a rating in excess of 30 percent for the Veteran's service-connected PTSD have not been met. 38 C.F.R. § 4.130, Diagnostic Code 9411. II. On and After September 9, 2013 On September 9, 2013, the Veteran underwent a VA examination. As a result of this examination, the Veteran was assigned a GAF score of 60. This score indicates that the Veteran's PTSD symptoms were moderate or that they resulted in moderate difficulty in social, occupational or school functioning. The Board also reviewed the September 9, 2013 VA examiner's clinical findings as to the severity of the Veteran's service-connected PTSD. See Carpenter, 8 Vet. App. at 242; see also 38 C.F.R. § 4.126; VAOPGCPREC 10-95. The September 9, 2013 VA examiner determined that the Veteran's ability to function occupationally was only mildly impaired, as the Veteran reported good work performance and attendance. The Veteran reported that he had been a machinist his entire professional life and that he continued to work in quality control. He stated that his job was going well and that he has a good relationship with his co-workers. Further, the Veteran stated that he had not been reprimanded, but that he had been told to calm down when he started to raise his voice. With respect to social interactions, the Veteran indicated that he continued to visit "the guys" at the local Veterans Service Organization, but denied having any close friends. The examiner found that the Veteran's PTSD caused mild to moderate difficulties with social interactions due to anxiety and irritability. The Veteran stated that he reads a lot as a hobby. The Veteran endorsed getting along well with his family, but stated that he and his wife of 44 years have not slept in the same bed for 15 years due to his restlessness and/or nightmares. He stated that his relationship with his wife "has its moments like any couple." The Veteran described his relationship with his children as "good," but that they say he is "different." He stated that his daughter had spoken to him about his temper/irritability. Overall, the examiner noted that the Veteran's PTSD symptoms primarily resulted in psychological distress, which was deemed to be moderate in severity. With respect to activities of daily living, the Veteran helped out with the laundry, but stated that his daughter did most of the household chores and his son did most of the outdoor chores. With that said, however, the Veteran stated that he could do more of the chores if his children were not there to help. He denied problems with maintaining personal hygiene. He endorsed being able to shop, but hates doing so due to being anxious around other people. The Veteran stated that he sometimes loses track of directions when driving and is easily anger, but does not act on it. Ultimately, the examiner determined that the Veteran's PTSD symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily with normal routine behavior self-care and conversation. As discussed above, a 50 percent rating has already been assigned to the Veteran's service-connected PTSD on and after September 9, 2013. Thus, in order for a higher rating to be warranted, the evidence during this period must demonstrate or more nearly approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. As demonstrated by the September 9, 2013 VA examination, the Veteran experienced mild impairment of occupational functioning. He continued to be employed in quality review, had good relationships with his co-workers, and his job was going well. The September 9, 2013 VA examination demonstrated that his ability to function socially was impaired mildly to moderately due to irritability and anxiety, but that he maintain friendship with "the guys" at the local Veterans Service Organization. These friendships were not close, however. The Veteran continued to be married to first wife of more than 44 years. He essentially described their relationship as typical, but stated that they do not sleep in the same bed together due to his restlessness/nightmares. His relationship with his children was good. The Veteran helped out with chores and maintained his personal hygiene. Based on this, the Board finds that the Veteran's PTSD does not cause or more nearly approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Id. Consequently, the Board finds that a rating in excess of 50 percent on and after September 9, 2013, for the Veteran's PTSD is not warranted. Mauerhan, 16 Vet. App. at 442-43. III. Extraschedular Generally, evaluating a disability using either the corresponding or an analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2013). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases, where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, the Rating Schedule contemplates then the Veteran's disability picture, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the already assigned ratings inadequate. The Veteran's service-connected PTSD is evaluated as a psychiatric impairment pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his disability. Id. When comparing the severity of the Veteran's PTSD and the associated occupational and social impairment, as detailed above, with that contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by the 30 percent rating and 50 percent rating already assigned before and after September 9, 2013, respectively. Schedular ratings in excess of those already assigned are provided for certain manifestations of PTSD, but the evidence demonstrated that the level of functional impairment contemplated by those manifestations was not demonstrated before or on and after September 9, 2013. The criteria for the already assigned ratings reasonably describe the Veteran's disability level and symptomatology both before and on and after September 9, 2013. Consequently, the Board concludes that the schedular evaluations are adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996); Mauerhan, 16 Vet. App. at 442-43. Finally, in reaching this decision, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against assigning ratings in excess of those already assigned to his service-connected PTSD, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial rating in excess of 30 percent prior to September 9, 2013, for PTSD is denied. Entitlement to a rating in excess of 50 percent on and after September 9, 2013, for PTSD is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs